1. No category

Child Physical and Sexual Abuse:
Guidelines for Treatment
Final Report: January 15, 2003
Prepared by:
National Crime Victims Research and Treatment Center
Medical University of South Carolina
Charleston, South Carolina
Center for Sexual Assault and Traumatic Stress
Harborview Medical Center
Seattle, Washington
A cooperative agreement funded by the:
Office for Victims of Crime
Office of Justice Programs
U.S. Department of Justice
Disclaimer
This project was supported by Grant No. 1999-VF-GX-K010
awarded by the Office for Victims of Crime, Office of Justice
Programs, U. S. Department of Justice. Points of view in this
document are those of the authors and do not necessarily represent
the official position or policies of the U. S. Department of Justice.
For more information about this project and report, contact:
Benjamin E. Saunders, Ph.D.
National Crime Victims Research and Treatment Center
Medical University of South Carolina
165 Cannon Street, Box 250852
Charleston, SC 29425
This document may be downloaded electronically at:
http://www.musc.edu/cvc/
Proper citation for this document is as follows:
Saunders, B.E., Berliner, L., & Hanson, R.F. (Eds.). (2003). Child Physical and Sexual
Abuse: Guidelines for Treatment (Final Report: January 15, 2003). Charleston, SC: National
Crime Victims Research and Treatment Center.
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Table of Contents
PROJECT STAFF ..................................................................................................................... 1
NATIONAL ADVISORY COMMITTEE ................................................................................. 2
CONTRIBUTORS .................................................................................................................... 3
INTRODUCTION .................................................................................................................... 5
Goals of the Project ....................................................................................................... 6
Challenges for Clinical Science ....................................................................................... 7
The Clinical Science Process and Child Victims .............................................................. 8
Figure 1. Ideal Clinical Science Process ......................................................................... 9
Figure 2. Common Clinical Science Process ................................................................ 10
Why Establish Guidelines Now? ................................................................................... 11
Clinical and Empirical Literature ....................................................................... 11
Responsibilities of Practitioners ........................................................................ 12
Role of the Guidelines ...................................................................................... 13
Use of the Guidelines ................................................................................................... 13
Clinical Innovation and Experimentation ........................................................... 14
Cultural Issues .................................................................................................. 14
Context of Treatment ....................................................................................... 16
PROCESS USED FOR DEVELOPING THE GUIDELINES .................................................. 17
Selection Criteria for Problem Areas and Treatments .................................................... 18
TREATMENT PROTOCOL CLASSIFICATION SYSTEM ................................................... 20
1 = Well-supported, efficacious treatment .................................................................. 20
2 = Supported and probably efficacious treatment ...................................................... 21
3 = Supported and acceptable treatment ..................................................................... 21
4 = Promising and acceptable treatment ...................................................................... 22
5 = Innovative or novel treatment ............................................................................... 22
6 = Concerning treatment ........................................................................................... 23
ASSESSMENT IN CASES OF CHILD ABUSE ..................................................................... 24
Special Issues in Child Abuse Cases ............................................................................. 24
Assessment of Children ................................................................................................ 25
Assessment of Parent/caregiver-child and Other Familial Relationships ......................... 26
Assessment of Parents .................................................................................................. 28
Use of Standardized Measures ..................................................................................... 29
Treatment planning ...................................................................................................... 29
Summary of Assessment ............................................................................................... 30
TREATMENT PROTOCOLS FOR CASES OF SEXUAL AND PHYSICAL ABUSE ........... 31
Child Focused Interventions ......................................................................................... 33
Cognitive-behavioral and Dynamic Play Therapy for Children with Sexual
Behavior Problems and Their Caregivers ............................................... 34
Cognitive Processing Therapy (CPT) ................................................................ 37
Eye Movement Desensitization and Reprocessing (EMDR) .............................. 39
Individual Child and Parent Physical Abuse-focused Cognitive-Behavioral
Treatment ............................................................................................. 43
Resilient Peer Training Intervention .................................................................. 45
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Therapeutic Child Development Program ......................................................... 47
Trauma-focused Cognitive-Behavioral Therapy (CBT) ..................................... 49
Trauma-focused Integrative-Eclectic Therapy (IET) ......................................... 52
Trauma-focused Play Therapy .......................................................................... 54
Family, Parent-Child and Parent-Focused Interventions ................................................ 56
Attachment-Trauma Therapy ............................................................................ 57
Behavioral Parent Training Interventions for Conduct-Disordered Children ...... 59
Corrective Attachment Therapy ........................................................................ 64
Family Focused, Child Centered Treatment Interventions
in Child Maltreatment .......................................................................... 66
Family Resolution Therapy (FRT) ..................................................................... 69
Integrative Developmental Model for Treatment of Dissociative
Symptomatology ................................................................................... 71
Intensive Family Preservation Services .............................................................. 73
Multisystemic Therapy (MST) for Maltreated Children and their Families ......... 75
Parent-Child Education Program for Physically Abused Parents ........................ 78
Parent-Child Interaction Therapy (PCIT) .......................................................... 81
Physical Abuse-informed Family Therapy .......................................................... 84
Parents United (Child Sexual Abuse Treatment Program) ................................. 86
Parents Anonymous .......................................................................................... 90
Offender Interventions ................................................................................................. 92
Adolescent Sex Offender Treatment ................................................................. 93
Adult Child Molester Treatment ....................................................................... 96
Summary of Treatment Protocols ................................................................................. 99
Table 1. Summary of Treatment Protocol Classifications ............................... 100
GENERAL PRINCIPLES FOR TREATMENT OF PHYSICAL AND SEXUAL ABUSE .... 104
Principles of Empirically Supported Treatments ......................................................... 104
General Principles of Treatment ................................................................................. 106
CONCLUSION ..................................................................................................................... 109
REFERENCES ..................................................................................................................... 110
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PROJECT STAFF
Project Co-Directors:
Benjamin E. Saunders, Ph.D.
Professor and Director
Family and Child Program
National Crime Victims Research and Treatment Center
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
Charleston, SC
Lucy Berliner, M.S.W.
Director and Associate Professor
Center for Sexual Assault and Traumatic Stress
Harborview Medical Center
Seattle, WA
Professional Staff:
Rochelle Hanson, Ph.D.
Associate Professor and Clinical Director
National Crime Victims Research and Treatment Center
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
Charleston, SC
Support Staff:
Kelley Christensen
Family and Child Program
National Crime Victims Research and Treatment Center
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
Charleston, SC
OVC Project Officers:
Marylouise Kelley
Marilyn Keel
Olga Trujillo
Michelle Avery Weston
Office for Victims of Crime
Office of Justice Programs
U. S. Department of Justice
Washington, DC
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NATIONAL ADVISORY COMMITTEE
Eliana Gil, Ph.D.
INOVA Kellar Center
Fairfax, VA
Lisa Amaya-Jackson, M.D.
The Center for Family and Child Health
Duke University Medical Center
Durham, NC
David Kolko, Ph.D.
Director, Special Services Unit
Western Psychiatric Institute and Clinic
University of Pittsburgh School of Medicine
Pittsburgh, PA
Barbara Bonner, Ph.D.
Center on Child Abuse and Neglect
Oklahoma Health Sciences Center
Oklahoma City, OK
Anthony Mannarino, Ph.D.
Center for Traumatic Stress in Children and
Adolescents
Allegheny General Hospital
Pittsburgh, PA
Mark Chaffin, Ph.D.
Center on Child Abuse and Neglect
Oklahoma Health Sciences Center
Oklahoma City, OK
Judy Cohen, M.D.
Center for Traumatic Stress in Children and
Adolescents
Allegheny General Hospital
Pittsburgh, PA
Mary Meinig, M.S.W.
Office of the Family and Children’s
Ombudsman, Office of the Governor
State of Washington
Tukwila, WA
Esther Deblinger, Ph.D.
Center for Children’s Support
School of Osteopathic Medicine
University of Medicine and Dentistry of
New Jersey
Stratford, NJ
Anthony Urquiza, Ph.D.
Child Protection Center
Department of Pediatrics
University of California Davis Medical
Center
Sacramento, CA
William N. Friedrich, Ph.D.
Department of Psychology
Mayo Clinic
Rochester, MN
Jeffrey N. Wherry, Ph.D., ABPP
Children's Advocacy Services of Greater St.
Louis
University of Missouri-St. Louis
St. Louis, MO
Thom Gauthier, M.S.W.
Executive Director
American Professional Society on the Abuse
of Children
Chicago, IL
David Wolfe, Ph.D.
Department of Psychology
University of Western Ontario
London, Ontario
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CONTRIBUTORS
Esther Deblinger, Ph.D.
Center for Children's Support
University of Medicine and Dentistry of
New Jersey
Stratford, NJ
Donya L. Adkerson, M.A., L.C.P.C.
Alternatives Counseling, Inc.
Edwardsville, IL
Barbara L. Bonner, PhD
Center on Child Abuse and Neglect
University of Oklahoma Health Sciences
Center
Oklahoma City, OK
John W. Fantuzzo, Ph.D.
Graduate School of Education
University of Pennsylvania
Philadelphia, PA
Charlotte Booth, MSW
Behavioral Sciences Institute
Federal Way, WA
William Friedrich, Ph.D, ABPP
Department of Psychiatry and Psychology
Mayo Clinic
Rochester, MN
Elizabeth Brestan, Ph.D.
Department of Psychology
Auburn University
Auburn, AL
Eliana Gil, Ph.D.
INOVA Kellar Center
Fairfax, VA
Mark Chaffin, Ph.D.
Center on Child Abuse and Neglect
University of Oklahoma Health Sciences
Center
Oklahoma City, OK
Rochelle F. Hanson, Ph.D.
National Crime Victims Research and
Treatment Center
Medical University of South Carolina
Charleston, SC
Claude Chemtob, Ph.D.
Mount Sinai School of Medicine
New York, NY
Scott W. Henggeler, Ph.D.
Family Services Research Center
Medical University of South Carolina
Charleston, SC
Gretchen Clum, Ph.D.
Center for Trauma Recovery
University of Missouri–St. Louis
St. Louis, MO
Beverly James, MSW
Honaunau, HI
Debra A. Johnson, Ph.D.
Parents United International, Inc.
Modesto, CA
Judy Cohen, M.D.
Center for Traumatic Stress in Children and
Adolescents
Allegheny General Hospital
Pittsburgh, PA
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Laura Sheehan, MA, NCC, CMHC
Childhaven, Inc.
Seattle, WA
David J. Kolko, Ph.D.
Special Services Unit
Western Psychiatric Institute and Clinic
University of Pittsburgh School of
Medicine,
Pittsburgh, PA
Joyanna Silberg, Ph.D.
Sheppard-Pratt Health System
Towson, MD
Forrest Lien, LCSW, ACSW
Attachment Center at Evergreen
Evergreen, CO
Polly B. Sosnowski, MSW
Lowcountry Children’s Center
Charleston, SC
Mary Meinig, MSW
Office of the Family and Children’s
Ombudsman
Tukwila, WA
Cynthia Cupit Swenson, Ph.D.
Family Services Research Center
Medical University of South Carolina
Charleston, SC
Holly Payne
Department of Psychology
Auburn University
Auburn, AL
Anthony J. Urquiza, Ph.D.
CAARE Center
Department of Pediatrics
University of California – Davis Medical
Center
M. Elizabeth Ralston, Ph.D.
Lowcountry Children’s Center
Charleston, SC
David Wolfe, Ph.D.
Department of Psychology
University of Western Ontario
London, Ontario
Canada
Patricia Resick, Ph.D.
Center for Trauma Recovery
University of Missouri–St. Louis
St. Louis, MO
Sheri Rosen
Parents Anonymous
Benjamin E. Saunders, Ph.D.
National Crime Victims Research and
Treatment Center
Medical University of South Carolina
Charleston, SC
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INTRODUCTION
One mission of the Office for Victims of Crime of the U.S. Department of Justice is
developing training and practice materials for police, prosecutors and court personnel on steps
that can be taken to improve the criminal justice response to children exposed to violence.
Thousands of abused children and their families become involved with the criminal justice
system each year, and they often are some of the most difficult cases to manage. A critical
function of victim advocacy is to insure that crime victims receive the support and intervention
they need to remedy the effects of crime. Victims who receive appropriate support are better
able to be cooperative with the criminal justice system, which enables the system to do its job
more effectively and efficiently. Child abuse is a crime that frequently results in serious mental
health problems for victims. Because it occurs behind closed doors and frequently has little
physical evidence, it is a crime that requires the cooperation and often the testimony of the
victim for successful prosecution. These tasks frequently are arduous for an abused child with
serious, abuse-related mental health difficulties. Therefore, helping child abuse victims receive
the mental health treatment they need is an important component of victim advocacy with
children, and benefits both the children and the criminal justice system.
As part of this work, the National Crime Victims Research and Treatment Center at the
Medical University of South Carolina and the Center for Sexual Assault and Traumatic Stress at
the Harborview Medical Center, University of Washington conducted a collaborative project
with the Office for Victims of Crime to develop guidelines for the mental health assessment and
treatment of child victims of sexual and physical abuse and their families. Many children are
treated each year for mental health problems associated with abuse. However, it is unclear how
many of these children receive state-of-the-art, abuse-specific mental health treatment. A
common complaint of therapists is that they often do not have ready access to the treatment
outcome research literature, and they do not have time to wade through a sea of academic
journals in search of the latest treatment information. Consequently, they often are concerned
about whether the treatment approaches they use are the best available, and seek more efficient
ways of learning about new clinical and research findings in their area.
The primary purpose of this project was to encourage the use of mental health treatment
protocols and procedures that have a sound theoretical basis, a good clinical-anecdotal literature,
high acceptance among practitioners in the child abuse field, a low chance for causing harm,
and empirical support for their utility with victims of abuse. To accomplish this purpose,
practitioners in the field need easily accessible information about available treatments, and
direction concerning appropriate treatment methods for the child victims with whom they work.
These Guidelines seek to present the best available information about the mental health
treatment of cases of physical and sexual abuse in a concise and consistent format that can be
easily used by practitioners and other interested professionals. The Guidelines are not intended
to be an exhaustive and comprehensive guide to all of the treatment modalities that have been
used with abused children. Rather, the Guidelines seek to cover the most common approaches,
the protocols with the most empirical support, theoretically sound and promising treatments that
may not have been tested empirically, and some practices that raise concern. The Guidelines can
be used to identify “first choice” treatments, i.e., those that have empirical support for their
efficacy; other treatments with strong clinical and theoretical support and wide acceptance
within the field; novel and innovative treatments that may be used with caution; and other
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interventions that lack empirical, clinical or theoretical support, should be considered
experimental or even potentially dangerous, and should not be used. By providing practitioners
with clear and succinct information and directions for how to obtain more detailed knowledge,
they will be better equipped to work with these child abuse victims and their families.
Goals of the Project
The primary goals of this project were:
1.
To develop specific criteria that can be used by clients, practitioners, agencies, payers,
and other concerned parties for judging the appropriateness and efficacy of treatment
procedures and protocols often used with abused children and their families.
2.
To describe important characteristics of treatment procedures and protocols commonly
used with abused children and their families in a concise and consistent manner that is
easily accessible by professionals.
3.
To classify commonly used treatment procedures and protocols according to their levels
of theoretical soundness, empirical support for their therapeutic efficacy and
effectiveness, clinical utility and applicability, and acceptance within the practitioner
community, and potential for harm.
4.
To develop a set of general guidelines for the clinical assessment and mental health
treatment of abused children and their families that can be applied to cases of physical
and sexual abuse.
The Guidelines are intended for use by mental health professionals, mental health
treatment programs, victim/witness advocates, family/juvenile court judges, prosecutors,
criminal court judges, child protective services personnel, and other practitioners who come into
contact with abused children and their families. Other intended audiences include state and
federal victims compensation programs, policy-makers, government mental health benefit
programs (e.g., Medicaid and Medicare), private insurance companies, health maintenance
organizations, related child abuse professionals, relevant professional organizations, and others
concerned with the treatment of abused children. The intent of the Guidelines is to raise the
standard of mental health care for abused children and their families by encouraging broader
application of theoretically sound, empirically supported, and clinically accepted mental health
treatment procedures. The Guidelines are designed to inform practitioners about the theoretical,
empirical, and clinical characteristics of certain treatment protocols, and to encourage them to
consider these characteristics carefully as they make their treatment decisions. The Guidelines
will help practitioners make informed choices in their treatment selection, and help them
understand the potential risks as well as benefits of specific treatment choices to their clients.
The Guidelines are designed to provide direction to the child abuse field by translating current
theory, research, and practice into practical recommendations for mental health treatment of
child abuse victims and their families.
The Guidelines are not designed to be followed rigidly in every case of child abuse, or
serve as a replacement for sound, case-specific clinical judgment. Nor are they intended to stifle
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clinical innovation. The complexity of child abuse cases means that practitioners frequently will
have to search for better ways of helping these children by using their clinical training,
experience, judgment, and creativity. The Guidelines are offered as a standard, based upon the
current research and clinical literatures, to inform practitioners about particular available
treatments and to aid in treatment decision-making. They can be used to appraise practice in
individual cases, to improve relevant policies and procedures, and to assess the array of effective
services available (or not available) in communities.
Challenges for Clinical Science
The primary challenge of clinical science is to discover what treatments are effective for
relieving what problems with what people in particular settings. This task applies to the
treatment of child abuse victims as well as other mental health clients. A significant body of
research has demonstrated that child physical and sexual abuse are significant risk factors for
many mental health disorders and problems, and that substantial proportions of children who are
victims of physical or sexual abuse develop serious emotional and behavioral difficulties
(Beitchman, et al., 1991; Beitchman et al., 1992; Boney-McCoy & Finkelhor, 1995; Briere &
Elliott, 1994; Browne & Finkelhor, 1986; Duncan et al., 1996; Felitti et al., 1998; Fergusson et
al., 1996; Flisher et al., 1997; Gomes-Schwartz et al., 1990; Hanson et al., 2001; Kendall-Tackett
et al., 1993; Kessler, Davis, & Kendler, 1997; Kilpatrick et al., 2000; Kilpatrick et al., in press;
Pelcovitz et al., 1994; Polusny & Follette, 1995; Saunders et al., 1992; Saunders et al., 1999).
Therefore, an important task of clinical science is to determine what treatments will be effective
in helping these child victims recover from these abuse-related problems.
However, simply developing and testing treatment protocols with this population will not
insure that victimized children will receive appropriate treatment. A second challenge is how to
disseminate theoretically sound and empirically supported treatments, and train front-line
practitioners in their use with child victims. Clinical science can do a wonderful job of
developing and testing good treatments. Unfortunately, if the front-line practitioner is not aware
of the work and is not trained to use good treatments, child victims will not benefit. Therefore,
effective dissemination is necessary for the clinical process to be useful, and is the major goal of
this report.
However, developing and testing good treatments and disseminating them to practitioners
also is not enough. A final challenge is how to motivate clinicians in the field to actually use
theoretically sound and empirically supported treatments. Mental health practitioners enjoy
wide latitude in what they can do with their clients. Independent practitioners can choose how
they are going to work with their clients with relatively little monitoring. Obviously,
practitioners want to help their clients improve and function well. That goes without saying.
Nevertheless, how clinicians choose to use certain treatment approaches and choose not to use
others can be a complex process that is only partially guided by theoretical or empirical support
for treatment protocols. However, getting information about the support for available and
commonly used treatments into the hands of front-line practitioners is a key element in
encouraging the use of sound and supported treatments. Providing such information is a critical
purpose of this report.
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The Clinical Science Process and Child Victims
Figure 1 illustrates an ideal view of the clinical science process with psychosocial
interventions. In this process an innovative therapy protocol is developed and used cautiously in
clinical settings. In a reciprocal relationship, clinical experience influences further development,
which is then tested again in clinical practice. Often an anecdotal or case study clinical literature
develops describing the treatment and the response of those with whom it has been used. At
some point the treatment is sufficiently well-developed and determined to have potential for
broader use. Efficacy studies are then conducted under carefully controlled conditions to
determine if the treatment is useful with the intended treatment population. If the treatment is
shown to have good empirical support when used in highly controlled and often academic
settings, effectiveness studies are conducted in more “real world” treatment delivery settings
using front-line practitioners. The utility of the treatment then can be tested in conditions like
those in which most clients are seen. If the treatment is shown to be efficacious and effective, it
is then disseminated to the field for wider use.
Ideally, this process would be applied to all treatments used with child victims of
physical and sexual abuse. Treatments for problems commonly experienced by child victims
would be developed and used with care and consent in clinical settings. Efficacy and
effectiveness studies would be conducted, and only those treatments shown to be effective with
child victims would be disseminated for use in community agencies. However, this ideal clinical
process is not what typically occurs. Figure 2 illustrates the much more common situation, and
the one that often has applied to the treatment of child victims as well. Treatment protocols are
developed in clinical settings. However, as illustrated by arrow A, therapy approaches often are
widely disseminated with little or no empirical testing. Dissemination is usually in the form of
books written by practitioners who have developed and found a particular approach to be helpful
in their work, and clinical training conducted at professional conferences and workshops. It
could be argued that this arrow illustrates the historically most common approach to treatment
development and dissemination in the child victim field. Arrow B illustrates the practice of
disseminating treatment protocols after their efficacy has been tested, but prior to effectiveness
studies being conducted. This course is also very common. In fact, true effectiveness studies are
relatively rare. In the child victim field, there is a growing treatment outcome literature
comprised of efficacy studies, and this information is gradually being disseminated as indicated
by arrow B.
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Use in
Clinical
Setting
Conduct
Effectiveness
Studies
Conduct
Efficacy
Studies
Develop
Tx Approach
Figure 1.
Ideal Clinical Science Process
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Disseminate
Treatment
to the Field
A
Use in
Clinical
Setting
Conduct
Effectiveness
Studies
Conduct
Efficacy
Studies
Develop
Tx Approach
B
Figure 2.
Common Clinical Science Process
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Disseminate
Treatment
to the Field
One could argue from a strictly scientific standpoint, that the processes depicted by
arrows A and B in Figure 2 are problematic. And, it is true that in a perfect world treatments
would flow through the process of Figure 1 and not be disseminated and adopted by clinicians in
the field until a convincing body of effectiveness research has been built. However, this
progression is not what happens generally. The process depicted in Figure 1 can take many
years and be very expensive. Given the relatively low resources given to testing treatments used
with child victims, the cost of testing treatments, and the length of time the ideal clinical process
takes, the accumulation of new empirical knowledge takes time. Given the demands of working
with child victims, it is unrealistic to expect practitioners to use only treatments that have been
through the process in Figure 1. There always will be a significant lag between clinical use and
extensive empirical testing of psychosocial treatments. Practitioners frequently use treatments
that have insufficient or even no empirical support, but appear to them to be theoretically sound
and clinically useful in meeting the needs of their clients. Whether this custom is appropriate or
not can be argued. However, it is a common practice.
Therefore, any attempt to develop guidelines for treatment must recognize the reality of
the child victim clinical world and acknowledge that treatments that have not been through the
ideal clinical process are commonly used with child victims, and that empirical support based
upon effectiveness studies cannot be the sole criteria for determining acceptable treatments for
practitioners in the field. Clearly, empirical support for either efficacy or effectiveness is a
strong and convincing reason for using a treatment. And, when a treatment has empirical
support, it should be considered superior and preferable to a treatment that does not. But, like
there are gradations of empirical support, other criteria for determining an acceptable treatment
must be used as well, particularly for problems for which no treatment has empirical support.
Consequently, providing practitioners information about the theoretical soundness of treatments,
their acceptability and use in the community, their potential for harm, as well as their empirical
support was an important goal of the guideline development process.
Why Establish Guidelines Now?
Clinical and Empirical Literature. Over the past two decades, the mental health
treatment of child victims of sexual and physical abuse and their abusive parents has received
much attention by both the clinical and research communities. There is now a substantial body
of research literature affirming the increased risk that child abuse victims have for various
mental health disorders and problems, and the factors that tend to mediate these risks (Beitchman
et al., 1992; Briere & Elliott, 1993; Duncan, et al., 1996; Epstein et al., 1998; Felitti et al., 1998;
Fergusson et al., 1996; Kendall-Tackett, Williams, & Finkelhor, 1993; Polusny & Follette, 1995;
Saunders et al., 1992; Mullen et al., 1994; Mullen et al., 1996). Relatively sophisticated theories
have been developed that explain these risk mechanisms and give direction to specific
approaches for clinical intervention (Briere, 1989; Cohen & Mannarino, 1996a; Deblinger, &
Heflin, 1996; Friedrich, 1990; Wolfe, 1987; Wolfe, McMahon, & Peters, 1997). Great strides
have been made in the development of assessment tools appropriate for use with child abuse
victims and parent-offenders (Briere, 1995; Briere, 1996; Friedrich, 1998a; Hodges, 1997;
Milner, 1994; Abel et al., 1998). Over the years, a large and rich clinical treatment literature has
developed describing interventions that appear to be theoretically sound and have good clinical
utility (e.g., Bolton & Bolton, 1987; Friedrich, 1990; Gil, 1996a; Gil, 1996b; Karp & Butler,
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1996; Maddock & Larson, 1995; Sgroi, 1982). Many of these treatments have been used by
practitioners for some time, and are well accepted in the field.
Most important, there now is a growing research literature testing the efficacy of mental
health intervention with these populations (Berliner & Saunders, 1996; Cohen, Berliner, &
March, 2000; Cohen & Mannarino, 1996b; Cohen & Mannario, 1998b; Deblinger, Lippmann, &
Steer, 1996; Finkelhor & Berliner, 1995; Kolko, 1996c). Though much research remains to be
done, the efficacy of at least some treatments for some problems exhibited by abused children is
supported theoretically, clinically, and empirically. Still other treatment protocols and
procedures have a solid theoretical basis, enjoy wide acceptance by practitioners in the field,
have considerable anecdotal support for their clinical utility, but have not been subjected to
empirical evaluation. Unfortunately, other treatments appear to have a relatively poor theoretical
foundation and little evidence indicating they are clinically effective. Many practitioners have
increasing worries that some types of theoretically questionable and empirically untested
interventions actually may be harmful to at least some recipients. This concern is founded since
there is evidence that some children deteriorate even after receiving treatments with empirical
support (Berliner & Saunders, 1996). Most important, child deaths have been reported as the
result of using some treatments (Crowler & Love, 2000; Fattah, 2002).
Because of this long history of clinical experience and the more recent empirical work,
the literature concerning the clinical treatment of problems associated with child abuse has
reached a critical mass. The field’s clinical experience with some treatment procedures and
protocols is long and the empirical research is growing. It is fair to say that mental health
practitioners now have a large body of clinical and empirical knowledge to draw upon when
developing treatment plans for abused children and their families. At this point, the literature is
robust enough to conclude that some treatments appear to work well with these clients, others
appear promising, while others are of questionable value.
It should be noted that other organizations have issued guidelines relevant to child
victims of physical and sexual abuse. For example, the International Society for Traumatic
Stress Studies has developed treatment guidelines for posttraumatic stress disorder (PTSD) in
children (Cohen, Berliner, & March, 2000), a common outcome of child victimization. The
Journal of Clinical Psychiatry developed a set of consensus guidelines for the treatment of
PTSD, including PTSD in children (Foa, Davidson, & Frances, 1999). The American Academy
of Child and Adolescent Psychiatry has developed practice parameters for the assessment and
treatment of children and adolescents with PTSD (American Academy of Child and Adolescent
Psychiatry, 1998). Several states have developed guidelines for treatment in child abuse cases
(The Clinical Committee of the Central Maryland Sexual Abuse Treatment Task Force, 1991;
CVCP Mental Health Treatment Guidelines Task Force, 1999). Therefore, other organizations
also have taken note of the state of the clinical and scientific literatures and considered them
sufficient to create treatment guidelines.
Responsibilities of Practitioners. Every day a great many children, parents, and
families are treated for problems associated with physical and sexual abuse. These vulnerable
clients are seeking help from serious problems, and practitioners know that great care should be
taken in selecting assessment and treatment protocols used with them. As noted above,
outpatient mental health practitioners have a great deal of independence and flexibility in
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choosing what treatments to use with their clients. With this independence comes a significant
level of responsibility and duty. In order to best treat their clients, practitioners have a duty to be
familiar with available interventions and their supporting literature. When proven treatments for
particular problems are available, responsible practitioners have a duty to be familiar with these
interventions and the supporting literature, to be trained and skilled in their use, and to use them
when appropriate. If they are not qualified to use the proven treatment, they have a
responsibility to refer clients to practitioners who are. Clinical decisions to use alternative
therapies should be made thoughtfully and be well-justified. Practitioners should refrain from
using experimental, concerning, or potentially dangerous treatments. In short, practitioners have
a duty to insure that their clients receive the most effective and appropriate treatment available.
Role of the Guidelines: Treatment guidelines will increase the likelihood that abused
children will get the best treatment available, based upon our knowledge today. Treatment
guidelines assist practitioners as they go about their work selecting which treatment procedures
to use with which clients by disseminating the best knowledge to the field in a concise way and
offering direction. Because much of the treatment outcome research has been conducted in
recent years, some practitioners may not be aware of these findings or their implications for
practice. It takes time for research findings and new clinical developments to percolate through
the field to front-line practitioners and be accepted and used on a regular basis. Guidelines
shorten this process by helping practitioners become aware of which treatments have strong
support, which are acceptable, and which are questionable. They encourage better assessment
and more appropriate treatment planning. Guidelines also can be used by judges, victim/witness
advocates, caseworkers and other professionals to assess the quality of care given to the child
victims for whom they are responsible.
To our knowledge, no organization or federal agency has developed guidelines
specifically for the mental health treatment of child victims of sexual and physical abuse and
their families. The level of knowledge and experience the field now has regarding the treatment
of abused children and their families is appropriate for the development of guidelines that can be
used by practitioners and other interested parties.
Use of the Guidelines
These Guidelines are intended for use by practitioners who deal with child abuse victims,
supervisors, agency administrators, program developers, payers and anyone concerned with the
mental health treatment of victims and families experiencing physical and sexual abuse. The
Guidelines provide criteria for judging the quality of mental health treatments, a base of
information describing available treatments, and a set of general guidelines for treatment based
upon the best scientific literature. All of this information is intended for use by practitioners and
other professionals in their treatment decision-making. The Guidelines will enable clinicians to
quickly examine the theoretical basis, components, empirical support and reference materials for
many available treatment protocols. Practitioners will be able to consult the Guidelines for
information about what specific treatment protocols have the most empirical and clinical support
as well as general principles for treatment. The Guidelines can be used as a reference source to
learn more about specific treatment protocols, and where to go for materials related to the
treatments. The Guidelines most obvious purpose is to guide treatment planning, treatment
selection, and clinical decision making with children who have been victims of physical or
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sexual abuse and their families. In addition, referral sources, victim advocates, payers, case
managers and others who refer child victims for services can use the Guidelines to help assess
the nature of treatment their clients are receiving. Non-clinicians, such as child protection
workers, guardians ad litem and CASAs, lawyers representing children and parents, and judges,
can use the Guidelines in making service plans that reflect the needs and problems of individual
cases. Policy makers and other officials can use the Guidelines to assess their communities to
see if appropriate treatment resources are in place for child victims.
The Guidelines are designed to encourage practitioners to use empirically supported
treatments when they are available and appropriate for the clients they see. When such
empirically supported treatments do not exist, treatments with a strong theoretical basis and wide
acceptance in the clinical community are appropriate. The major goal of the Guidelines is to
promote the use of treatments that have a sound theoretical basis, demonstrated clinical efficacy,
wide acceptance in the field, and little danger of causing harm. The hope is that clinicians will
use proven and accepted treatments as their first response to cases of child abuse, and limit their
use of concerning treatments that have a significant potential for harm.
Clinical innovation and experimentation. Though the Guidelines seek to promote the
use of effective and proven treatments, they were not developed to impose a rigid and inflexible
standard of care on individual cases. Child abuse cases often are enormously complicated and
frequently require considerable clinical innovation, judgment, and flexibility. However, the
Guidelines acknowledge that much is known about treatment with these clients, and that
responsible practitioners have a duty to be aware of the treatment literature and to use clinically
sound, empirically supported, and accepted treatments as their first choice. The Guidelines
acknowledge that appropriate, measured, and cautious clinical innovation is often necessary in
complex child abuse cases. However, clinical innovation should begin from a sound foothold in
the empirical and clinical literature, and be used when accepted treatments are found to be
inadequate in a particular case. The Guidelines are not intended to stifle clinical innovation
when it is required. However, cautious and reasoned practice innovation should not tip into
uninformed experimentation. The Guidelines are not intended to inhibit new treatment
development, scientific research, and experimentation. These are ongoing activities that need to
be carried out and even expanded. In fact, the Guidelines repeatedly point to where new
research is desperately needed. However, everyday practice is not the place for experimentation.
Experimentation and research should take place with appropriate human subject protections,
informed consent procedures, risk controls, and oversight by responsible organizations. The
Guidelines help delineate the line between innovation and experimentation.
Cultural Issues. Cultural competence in treatment is critical to adapting mental health
treatment paradigms to clients from diverse cultural, religious, and racial/ethnic groups. It is
well known in the general mental health services literature that cultural, religious and
racial/ethnic groups may vary in their helpseeking practices, and that mental health care in
particular may be perceived quite differently by diverse groups. Different cultural groups likely
have varying norms regarding many relevant issues, such as the role of the family, styles of
coping with adverse life events, the cultural meaning of specific symptoms, the meaning of
certain adverse life events, manners of trust and mistrust, stigma associated with mental health
needs, and reliance on informal sources of help and care (U.S. Department of Health and
Human Services, 2001). Language concerns, levels of acculturation, past experiences with
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governmental authorities, a history of racism and discrimination, and many other issues may
affect some people’s willingness to seek or engage in formal mental health care. Concerns about
the ethnicity or culture of the therapist, perceived clinician bias, or fears of stereotyping may
affect people’s willingness to engage in and remain in mental health care. Of course, the
importance of cultural competence is not limited only to families from racial, ethnic, religious,
or cultural minorities. Rather, understanding the cultural context of all client families is critical
to treatment. Therefore, clinicians should explore with client families their cultural, religious,
and ethnic identities and seek an understanding of how these factors may be relevant to the
presenting problems and their care.
Intervention for problems related to child abuse must be set within this larger mental
health context regarding cultural, religious, and racial/ethnic groups. Core individual and
familial values and beliefs are directly relevant to the treatment of all cases of child abuse.
Values and beliefs about issues pertinent to child abuse, such as sexuality, nudity, discipline
practices, family boundaries, respect for elders, personal and familial privacy, family roles,
acceptance of strangers, and help-seeking attitudes, are all influenced and often directly guided
by a family’s cultural, religious, and racial/ethnic identification. Perceptions about the
helpfulness and purpose of mental services often must also be addressed. Therefore, discerning,
understanding, and accommodating to the root value and belief structure of every family they
treat is a fundamental skill required of therapists working with victims of child abuse and their
families.
Many studies investigating questions germane to the treatment of victims of child abuse
and their families, such as abuse effects, abuse-related cognitions, and mediational models, as
well as treatment outcome, have included substantial proportions of participants from varied
cultural and ethnic groups (Cohen & Mannarino, 1996b; Boney-McCoy & Finkelhor, 1995;
Epstein et al., 1998; Saunders et al., 1992; Saunders et al, 1999) . And, potential differences
between racial and ethnic identification groups are often examined (Crouch et al, 2000).
However, most have focused on Caucasian and African-American participants, with some
having a good representation of Hispanic/Latino populations. Other racial/ethnic and cultural
groups are often under-represented and not examined. Surprisingly, the role of religious
identification is rarely examined despite the importance of religion on core values and beliefs.
Thus far, the limited number of treatment studies conducted have found few differences in the
response to treatment between racial and ethnic groups, which is encouraging. Thus far, the data
suggest that some treatments are generalizable across cultural and ethnic groups with little
modification. However, much work remains to be done in this area, particularly with less
prevalent cultural and ethnic groups. The potential impact of racial/ethnic identification,
religious identification, and cultural background on the effects of many treatment models is
simply unknown.
In an excellent review of the empirical literature on the treatment of abused and
neglected children, Cohen, Deblinger, Mannarino, and de Arellano (2001) examine the influence
of culture on the development of abuse-related symptoms, treatment preference, and treatment
response. They suggest there is limited research on cultural considerations in treatment of
abused and neglected children because treatment efficacy research in this area is relatively new.
Demonstrated efficacy of a treatment approach is needed before examining the potential
moderating effect of cultural, religious, and racial/ethnic factors. A limited number of research
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studies have suggested that there may be racial or ethnic differences in symptom development
following abuse. However, it is still unclear whether these differences are a function of cultural
background or whether these differences may be due to differences in the prevalence of abusespecific factors such as type of abuse or abuse incident characteristics (e.g., fear of injury or
death, physical injury, relationship of the perpetrator to the victim, etc.) between groups. They
suggest that more research is needed to understand the role of culture and ethnicity on treatment
outcome, controlling for the impact of abuse incident characteristics and other contextual factors.
With regard to potential differences in treatment preference across cultural groups, data
have been limited, but encouraging. Although more recent studies have included representations
of different racial/ethnic groups (Berliner & Saunders, 1996; Deblinger, Lippman, & Steer,
1996), most have not reported specific analyses that would allow us to draw firm conclusions
regarding cultural differences in treatment response. Those studies that have specifically
analyzed for treatment response as a function of race/ethnicity have indicated few differences in
treatment outcome (Cohen & Mannarino, 1996a, 1996b, 1998b; Lanktree & Briere, 1995; Kolko,
1996c). Unfortunately, these studies generally lack sufficient group sample sizes and statistical
power to accurately detect how participants from varied culture or ethnic groups may
differentially respond to treatment. However, the data do suggest that other factors (e.g., type of
treatment provided, child’s abuse-related cognitions, parental emotional distress, parental
support) appear to be more important in predicting treatment outcome than race or ethnicity. In
other words, it appears that there are certain abuse-specific factors related to treatment response
that cut across different cultural and ethnic groups, suggesting that these may be more important
than cultural identity. However, Cohen et al. (2001) point out that certain cultural groups may be
more accepting of psychological services because of their inherent value systems. Therefore,
one critical role of culture and ethnicity may be in affecting willingness to engage and maintain
in treatment, and expectations about treatment, rather than the technical impact of the treatment
itself. Given these limited findings, the role of cultural, racial, ethnic, and religious
identification on treatment response in cases of child abuse remains an important area for future
research, and needs to be considered in all treatment planning decisions.
Context of Treatment. The Guidelines are concerned with describing mental health
interventions for the identified problems and needs of abused children and their families.
However, these services are only one aspect of a community response to abused children and
their families, and usually are not the first order of business. In most cases child protection and
criminal justice investigations, and legal proceedings will take place before or concurrently with
the delivery of mental health services. Sometimes the abuse allegations will be disputed, or
parents will not agree with professionals about the nature of problems or the need for services.
In many instances involvement with treatment services will be the result of plans developed by
authorities and imposed on reluctant families. Practitioners who work with child abuse are
expected to be sensitive to and knowledgeable about the impact of these circumstances on
families who are entering treatment. Extra effort may need to be spent clarifying roles,
responding to concerns about confidentiality, and engaging families in the treatment process.
Treatment procedures may need to be adjusted to accommodate the context and circumstances in
which they are delivered. Again, the Guidelines should be used as a basis for treatment in these
situations, but should not dampen appropriate innovation.
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PROCESS USED FOR DEVELOPING THE GUIDELINES
A multi-stage process was used to develop the Guidelines. First, a distinguished National
Advisory Committee was assembled (see roster on page 2). This committee consisted of
nationally known clinicians, researchers, educators, and administrators who have been leaders in
developing, testing, teaching, and implementing treatment programs for abused children.
Committee members were drawn from different professional disciplines and work settings, and
represented diverse theoretical perspectives concerning treatment approaches. Second, this
Committee developed the process for constructing the Guidelines, including their structure, the
criteria that would be used to select and assess the various treatment protocols to be included,
principles of assessment and the general principles of treatment. Third, after the procedures
were established, either the developers of the selected treatments, a primary proponent of the
treatment, the program director, or a person who had conducted specific research on the
treatment was asked to write a brief description of the protocol following a set structure. These
descriptions were then edited by Guidelines staff and returned to the original author for approval.
Fourth, a classification ratings for each protocol was assigned to the treatment based upon the
classification criteria presented below. These classifications were reviewed by the National
Advisory Committee, further revised and finalized.
The first draft of general principles for treatment was generated by the National Advisory
Committee. Based upon the results of the treatment classification process, additional comments
by the National Advisory Committee, and comments from practitioners in the field, these general
principles were revised several times. During this initial development period, four presentations
were made at professional conferences describing the Guidelines, and comments and input from
practitioners in the field were received. All portions of the Guidelines were revised in response
to these comments.
An initial draft of the Guidelines was made public on June 1, 2000. This draft version
was disseminated for comment to staff and grantees of the Office for Victims of Crime,
members of the National Advisory Committee, and other interested professionals. The draft was
posted on the web site of the National Crime Victims Research and Treatment Center
(http://www.musc.edu/cvc/), and all concerned were encouraged to download and review it.
Immediately after the release of this draft, the project co-directors made six presentations at
national professional conferences describing the Guidelines and receiving comments from
practitioners in the field. Significant feedback was also received from the field via the Internet.
From June, 2000 through January, 2001, the Guidelines were downloaded over 1700 times. As a
result of these dissemination activities, many comments and suggestions were received
concerning the draft Guidelines. Comments were received from members of the National
Advisory Committee, members of professional audiences who participated in conference
presentations on the Guidelines, and professionals in the field who reviewed them. Comments
came from professionals from many disciplines, from all sections of the country, and from
countries outside the U.S. as well. Approximately 90-100 of the comments from the field
contained substantive and important suggestions for the guidelines. A second draft of the
Guidelines was released on March 30, 2001 that incorporated suggestions and comments
received since the June, 2000 draft was released. A third draft was released on July 30, 2001.
At that time the Guidelines had been downloaded over 2,000 times and over 300 substantive
comments had been received from the field and incorporated into the draft. This draft was
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delivered to the Office for Victims of Crime (OVC) of the U.S. Department of Justice. OVC
staff then conducted their own internal review of the Guidelines and sent them for independent
review by external experts. During this period, presentations on the Guidelines were made at
eight professional conferences, and feedback received. The Guidelines have been accessed or
downloaded on average 200 times per month since the July 30, 2001 release. This final version
of the Guidelines (December 6, 2002) is the result of this extensive review and revision process.
Selection Criteria for Problem Areas and Treatments
The focus of the guidelines is on psychotherapeutic or psychosocial treatment modalities
targeting problems with child victims, parent offenders, other family members, family
relationships and the family system as a whole to address mental health and psychosocial
problems specifically associated with physical and sexual abuse. Because of the extensive
literature linking many problems to a history of child abuse, criteria were established to select
the types of problems and subsequent interventions to be included in the Guidelines. The
selection criteria recognize that while some problems are frequent sequelae in child abuse cases
(e.g., posttraumatic stress, depression, sexual behavior problems), none are exclusive to child
abuse and all can result from other circumstances. For example, depression, aggressive
behavior, disrupted parent-child relationships, and inconsistent or coercive parent practices also
occur in children and families without a history of child abuse. Fortunately there is a clinical
and scientific literature documenting the utility of treatment for these conditions, and in many
cases, treatments developed for these problem areas have been modified for use in child abuse
situations. Therefore, the criteria do not focus only on problem areas that are most closely
associated with child abuse cases. They also include problems that often occur in child abuse
cases, but also may arise in other situations as well. Some problem areas that often occur in
child abuse situations or may be long term effects of child abuse are not included intentionally
because there is a well-developed and well-known separate treatment literature (e.g., substance
abuse, depression) that is beyond the scope of these Guidelines.
As noted above, the clinical literature describing possible treatment approaches in cases
of child abuse is extensive. The large portion of this literature describes procedures that have
been developed by individual clinicians, used in their own work, and possibly used by some
other clinicians in other settings. While many of these treatments meet some of the criteria
presented below, relatively few have been tested empirically. Because the literature is so large,
every treatment protocol that has been proposed for use with child abuse cases could not be
included in the Guidelines. Also, many of these protocols overlap greatly and contain many of
the same elements. Consequently, to include them all would mean a great deal of repetition.
Therefore, in choosing which protocols to include in the Guidelines, certain preferences were
used. If a treatment had been tested empirically in any scientifically reasonable fashion, it was
included. If a treatment is commonly used in the field with abused children, it was included. If
a treatment had been proven empirically to be useful with other populations and was being
applied to abuse populations, it was included. Treatments for which manuals, books, or other
writings describing their components and application were readily available were given
preference. Treatments that are representative of a general class of treatments that are
commonly used (e.g., parent training) or are somehow significant to the field of child abuse were
included (e.g., Parents Anonymous). Attempts were made to include multiple treatments for
treating victims, parents, and families. However, many books and articles available that describe
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treatment protocols suggested for use with abused children and their families that were not
included in the Guidelines due to space and resource limitations. The following criteria were
used to select treatments and classes of treatments:
Criterion 1.
There is significant research or overwhelming clinical opinion that a particular
mental, emotional, or behavioral disorder or problem is clearly associated with or
a result of either sexual abuse or physical abuse.
Criterion 2.
A treatment protocol exists that targets the disorder or problem associated with
child physical or sexual abuse.
Criterion 3.
Writings describing the treatment protocol are available to clinicians in the field.
Criterion 4.
The treatment protocol was developed for use by clinicians working in common
treatment settings in the field, or specialists in this treatment modality available
for referral.
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TREATMENT PROTOCOL CLASSIFICATION SYSTEM
A primary goal of this project was to establish a clear, criteria-based system for
classifying interventions and treatments according to their theoretical, clinical, and empirical
support. This system can be applied not only to the treatment protocols presented in these
Guidelines, but also can be used to judge the utility of other current treatments and treatments to
be developed in the future. Therefore, the classification system is a tool that can be used by
practitioners and others to make decisions about the appropriateness of certain treatments that
are not included in these Guidelines. Further, the Guidelines reflect the state of knowledge at the
time of writing. Hopefully, more research will be conducted testing the effects of existing
protocols. Consequently, treatments likely will change their classifications over time as more
research is completed. Therefore, the treatment classification system is a tool that can be applied
to a dynamic area where information is constantly increasing.
The classification system uses criteria regarding a treatment’s theoretical soundness,
clinical support, acceptance within the field, potential for harm, documentation, and empirical
support to assign a summary classification score. A lower score indicates a greater level of
support for the treatment protocol. The summary categories are:
1=
2=
3=
4=
5=
6=
Well-supported, efficacious treatment
Supported and probably efficacious treatment
Supported and acceptable treatment
Promising and acceptable treatment
Innovative or novel treatment
Concerning treatment
Specific criteria for each classification system category are presented below:
1.
Well-supported, Efficacious Treatment
1.
The treatment has a sound theoretical basis in generally accepted psychological
principles.
2.
A substantial clinical-anecdotal literature exists indicating the treatment's value
with abused children, their parents, and/or their families.
3.
The treatment is generally accepted in clinical practice as appropriate for use with
abused children, their parents, and/or their families.
4.
There is no clinical or empirical evidence or theoretical basis indicating that the
treatment constitutes a substantial risk of harm to those receiving it, compared to
its likely benefits.
5.
The treatment has a book, manual, or other available writings that specifies the
components of the treatment protocol and describes how to administer it.
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2.
3.
6.
At least two randomized, controlled treatment outcome studies (RCT) have found
the treatment protocol to be superior to an appropriate comparison treatment, or
no different or better than an already established treatment when used with abused
children, their parents, and/or their families.
7.
If multiple treatment outcome studies have been conducted, the overall weight of
evidence supports the efficacy of the treatment.
Supported and Probably Efficacious Treatment
1.
The treatment has a sound theoretical basis in generally accepted psychological
principles.
2.
A substantial clinical-anecdotal literature exists indicating the treatment's value
with abused children, their parents, and/or their families.
3.
The treatment is generally accepted in clinical practice as appropriate for use with
abused children, their parents, and/or their families.
4.
There is no clinical or empirical evidence or theoretical basis indicating that the
treatment constitutes a substantial risk of harm to those receiving it, compared to
its likely benefits.
5.
The treatment has a book, manual, or other available writings that specifies the
components of the treatment protocol and describes how to administer it.
6.
At least two studies utilizing some form of control without randomization (e.g.,
matched wait list, untreated group, placebo group) have established the
treatment's efficacy over the passage of time, efficacy over placebo or found it to
be comparable to or better than an already established treatment.
7.
If multiple treatment outcome studies have been conducted, the overall weight of
evidence supports the efficacy of the treatment.
Supported and Acceptable Treatment
1.
The treatment has a sound theoretical basis in generally accepted psychological
principles.
2.
A substantial clinical-anecdotal literature exists indicating the treatment's value
with abused children, their parents, and/or their families.
3.
The treatment is generally accepted in clinical practice as appropriate for use with
abused children, their parents, and/or their families.
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4.
There is no clinical or empirical evidence or theoretical basis indicating that the
treatment constitutes a substantial risk of harm to those receiving it, compared to
its likely benefits.
5.
The treatment has a book, manual, or other available writings that specifies the
components of the treatment protocol and describes how to administer it.
6.
a.
At least one group study (controlled or uncontrolled), or a series of single
subject studies suggest the efficacy of the treatment with abused children,
their parents, and/or their families, OR
b.
a treatment has demonstrated efficacy with other populations, has a sound
theoretical basis for its use with abused children, their parents, and/or their
families, but has not been tested or used extensively with abused
populations.
7.
4.
5.
If multiple outcome studies have been conducted, the overall weight of evidence
supports the efficacy of the treatment.
Promising and Acceptable Treatment
1.
The treatment has a sound theoretical basis in generally accepted psychological
principles.
2.
A substantial clinical-anecdotal literature exists indicating the treatment's value
with abused children, their parents, and/or their families.
3.
The treatment is generally accepted in clinical practice as appropriate for use with
abused children, their parents, and/or their families.
4.
There is no clinical or empirical evidence or theoretical basis indicating that the
treatment constitutes a substantial risk of harm to those receiving it, compared to
its likely benefits.
5.
The treatment has a book, manual, or other available writings that specifies the
components of the treatment protocol and describes how to administer it.
Innovative or Novel Treatment
1.
The treatment may have a theoretical basis that is an innovative or novel, but
reasonable, application of generally accepted psychological principles.
2.
A relatively small clinical literature exists to suggest the value of the treatment.
3.
The treatment is not widely used or generally accepted by practitioners working
with abused children.
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6.
4.
There is no clinical or empirical evidence or theoretical basis suggesting that the
treatment constitutes a substantial risk of harm to those receiving it, compared to
its likely benefits.
5.
The treatment has a book, manual, or other available writings that specifies the
components of the treatment protocol and describes how to administer it.
Concerning Treatment
1.
The theoretical basis for the treatment is unknown, a misapplication of
psychological principles, or a novel, unique, and concerning application of
psychological principles.
2.
Only a small and limited clinical literature exists suggesting the value of the
treatment.
3.
There is a reasonable theoretical, clinical, or empirical basis suggesting that
compared to its likely benefits, the treatment constitutes a risk of harm to those
receiving it.
4.
The treatment has a manual or other writings that specifies the components and
administration characteristics of the treatment that allows for implementation.
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ASSESSMENT IN CASES OF CHILD ABUSE
A basic principle of all clinical practice is that assessment should precede the initiation of
interventions. Based upon the results of the assessment, a treatment plan should be developed
that is tailored to the problems and needs of individual family members and the family as a
whole. The likelihood of successful outcome is enhanced substantially when effective
interventions are matched correctly to specific problems discerned through appropriate
assessment. A mismatch of treatment to problem is at best a waste of scarce resources, and can
prolong suffering, lead to deterioration in the client, or even endanger children. Most important,
when proper assessment is not conducted or the treatment approach fails to target the problems
identified, children do not receive the treatment they need for the problems they have.
Assessment is also an integral component of the ongoing treatment process. Periodic evaluation
of previously identified problems, emergent problems, and treatment progress are necessary
parts of therapy. Ongoing assessment results provide feedback about whether the target
problems have resolved or if a different intensity or type of therapy is indicated. All of these
generally accepted principles of assessment apply to cases of child abuse.
Special Issues in Child Abuse Cases
Child maltreatment cases have special characteristics that must be addressed in
assessment. The most important of these is determining how safe the living environment is for
the child victim. Since many abused children continue to live with the caregivers or siblings
who have hurt them or in families where domestic violence occurs, this focus on safety is a
priority. Therefore, understanding the level of risk for harm in the child’s environment and
subsequent safety planning are the first steps in assessment in abuse cases. Evaluation of risk
identifies what structural and contextual interventions may be necessary (e.g., separation,
professional supervision, chaperone program), as well as initial treatment targets (e.g., parental
substance abuse, behavior management skills, anger control). It also forms the basis for clinical
assessment and intervention. For example, even if children exhibit posttraumatic stress
symptoms, it is difficult to proceed in therap`y while they are still in dangerous (and fearproducing) situations. Treatment of fear and anxiety symptoms likely will be fruitless or even
harmful because it would be appropriate for a child to continue to be afraid and vigilant in such a
situation. If treatment continues, children may be desensitized to real danger cues, placing them
at greater risk in the future. Therefore, evaluation of environmental and contextual risk and
safety is a unique and critical part of the assessment process in abuse cases.
Another special consideration in abuse cases is the stance of caregivers with regard to the
charges of maltreatment. In many cases parents enter or bring their children to treatment
because child protection authorities have intervened and recommended or required their
attendance. In some cases they may be seeking treatment only because they are court-ordered to
do so. Parents may dispute the abuse allegations or minimize the harmful impact on their
children. Assessment of parental perceptions and stage of readiness to change is a central
ingredient of developing a meaningful treatment plan. Successful therapy outcome for
maltreated children who live with their parents and for parental deficits requires some degree of
cooperation with a treatment process. Belief and support by a non-offending parent has been
shown to contribute to the treatment of child distress in sexual abuse situations (Cohen &
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Mannarino, 1998a). Identifying the nature and extent of the obstacles to parental engagement
provides direction for the focus of treatment especially in the early stages of intervention.
Assessment of Children
Maltreated children often have emotional or behavioral problems as a result of their
abuse experiences or their abusive family environment. As noted above, substantial research has
documented the types of problems and mental health disorders frequently experienced by abused
children. These common problems include fear, anxiety, posttraumatic stress symptoms,
depression, sexual difficulties, poor self-esteem, stigmatization, difficulty with trust, cognitive
distortions, difficulty with affective processing, aggression, disruptive behavior, peer
socialization deficits, and other problems. Consequently, each of these problems that are
commonly exhibited by abused children should be assessed carefully using the best assessment
tools available.
The nature and severity of disturbance can vary substantially from child to child. In
some cases, abused children will not exhibit any clinically significant distress at initial
assessment. A review of clinical studies of sexually abused children found that up to 40% of
children, depending on the outcome, were apparently asymptomatic (Kendall-Tackett, Williams,
& Finkelhor, 1993). Other abused children will be terribly disturbed and suffer from major
mental health disorders, and still others will have moderate problems. The absence of detectable
problems may be the result of active symptom suppression by the child, avoidance coping
strategies, or simple resilience. At least some of these asymptomatic children will have a
delayed onset of disturbance (Gomes-Schwartz et al., 1990; Kendall-Tackett et al., 1993;
Mannarino et al., 1991). That is, they will develop abuse-related problems months or even years
after the abuse has stopped. Therefore, assessment should consider risk factors for the
development of future problems, as well as reported difficulties.
The first task of assessment involves determining the direct effects of the abusive events,
i.e., those problems that clearly stem squarely from the abusive behaviors experienced by the
child and likely have no other significant etiology. For example, probably the most abusespecific outcome of physical or sexual abuse experiences is posttraumatic stress symptoms.
About half of sexually abused and one third of physically abused children will meet diagnostic
criteria for posttraumatic stress disorder (PTSD), and more will have at least some posttraumatic
stress symptoms (McLeer et al., 1998; McCloskey & Walker, 2000). Therefore, PTSD
symptoms should be targets for evaluation. Screening for posttrauma symptoms requires that the
experience be explicitly discussed so that re-experiencing and avoidance symptoms can be
assessed. Numbing and hyperarousal symptoms may not be identified without specific inquiry.
Consequently, assessing for PTSD requires directly approaching the abuse experiences in the
evaluation process. This axiom is true for other abuse-related fears and anxieties as well.
Assessment of abused children should be abuse-informed, but not exclusively abusefocused. That is, the assessment should evaluate not only the potential problems that are the
direct effects of abuse, but also pre-existing and concomitant difficulties as well. The abuse
informed component of assessment should address cognitions as well as symptoms. Abusespecific (e.g., self-blame, guilt) and abuse-related (e.g., stigmatization, shame) attributions are
associated with increased distress and may lead to conditions such as depression, low self
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esteem, and impaired socialization that are common in abused children. For the most part,
practitioners must rely on clinical interviews to determine whether children have maladaptive
beliefs about their experiences.
Some behavior problems are common among maltreated children, although they can have
other etiologies. For example, sexual behavior problems are noted in about one-third of sexually
abused children (Friedrich, 1993). Anger control problems and aggression are frequently
observed in physically abused children (Kolko, 2002). These disruptive behaviors may be the
result of intense negative emotions associated with maltreatment or learned responses to the
experiences. However, they can also arise from causes other than abuse. Comprehensive
assessment will include targets that are commonly exhibited by abused children, even though
they may have other causes.
In addition to the abuse focus of assessment, abused children also should be evaluated for
the presence of emotional and behavioral problems that may or may not be the direct result of
the abuse experiences, but none the less impair functioning. Diagnostic interviews and
standardized behavior checklists can be useful in assessing for these problems. At minimum,
evaluators should screen for the presence of depression, anxiety disorders, and disruptive
behavior disorders.
It goes without saying that assessment of children should be developmentally informed.
One consequence of abuse and reactions to abuse is that the developmental trajectory of the child
victim is derailed. What may begin as an abuse-specific symptom (e.g., decreased concentration
due to re-experiencing symptoms) can lead to problems of functioning (e.g., poor school
performance, poor occupational achievement), which may produce negative socialization
patterns (e.g., association with delinquent peers), that can create risk for serious pathology (e.g.,
substance abuse, delinquency). Or the pathway to disrupted development may be quite direct
(e.g., aggression or early sexualization) and will interfere with normal peer social relationships.
One assessment approach is to determine systematically the level of functional impairment or the
degree to which children are having difficulties in role functioning at home, school, in the
community and in their behavior with others.
Assessment of Parent/Caregiver-Child and Other Familial Relationships
Parent/caregiver-child relationship quality is a critical part of any abuse case and should
be a target of assessment (Lipovsky et al., 1993). Assessment and treatment must pay attention
not only to the offender-victim portion of the relationship, but also the parent-child aspect
(Saunders & Meinig, 2000), which may be more important to the child. Common areas of
assessment are similar to targets of assessment in any family case and include parent-child
communication, affectional connection, styles of conflict management, discipline practices, and
levels of trust. A special point of assessment is insecure parent-child attachment. Insecure
attachment often is associated with abuse experiences either as a precursor to abuse or a result.
This problem tends to significantly disrupt parent-child relationships, and is presumed to set the
stage for lifelong problems in relating to others as children acquire working models for
interpersonal relationships within their families. Assessment of attachment style in the clinical
setting is generally based on the reports of children and parents about the quality of the
relationship, as well as observations of parent/caregiver-child interactions. There are a number
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of ways to make crude classifications. For example, one way to think about attachment style is
children’s valuations of self and others, with secure children evincing consistent positive views
of self and others, while insecure children tend to have either negative perceptions of
themselves, others or both. Parental responses to children can also be evaluated in terms of the
degree to which they are responsive versus inconsistent, distant, or a source of danger.
Classifying children into one of the insecure attachment categories is less important clinically
than assessing the nature and quality of parent-child relationships, and identifying problematic
relationships that should be a treatment focus.
While the importance of evaluating and addressing children’s capacity to form and
maintain successful relationships is not disputed, there are controversies about the determination
of attachment problems in children. It is not uncommon for some abused children to be labeled
“attachment disordered” or given the diagnosis of Reactive Attachment Disorder, despite the fact
that the dimensions of the diagnostic category have not been fully clarified (Hanson & Spratt,
2000). Anecdotally, there is reason to be concerned that in some cases, application of the label
or diagnosis may lead to very negative or even hopeless perceptions of these children. This is of
special concern for children in foster care who may have options for permanency or adoption
foreclosed because of the associated stigma. Assessment for attachment problems should clearly
specify the basis for drawing conclusions and the nature of the disturbance in order to form a
basis for treatment interventions.
Parental approaches to discipline should be an important focus evaluation in all cases,
and should not be limited to cases referred for physical abuse. Inconsistent, ineffective, or
coercive discipline practices create negative interactional patterns and child behavior problems.
They may also lead to physical abuse in an escalating cycle of child misbehavior, parental
frustration and loss of control that leads to abuse. The practices of nonoffending as well as
abusive parents should be assessed. Nonoffending parents may be contending with children’s
abuse related-symptoms or reactions to the family disruption at a time when they feel
overwhelmed. Many cases of less serious physical abuse are the result of discipline gone too far.
Exploration of how parents handle children’s misbehavior will identify areas for inclusion in the
treatment plan.
Family system characteristics, sibling relationships, extended family relationships, and
couple/marital and sexual relationships between parents are also important areas of assessment
and possible intervention (Nash et al., 1993; Dadds et al., 1991; Saunders et al., 1995; Smith &
Saunders, 1995). Several studies have found that abusive families tend to be more socially
isolated, have more rigid patterns of interaction, value familial control over individual behavior,
are more likely to have authoritarian interpersonal styles, and have significant levels of marital
and sexual relationship dissatisfaction. These family system and marital/couple factors often
constitute a context for abuse to emerge and be maintained. Therefore, marital and family
relationships and system characteristics are appropriate targets of clinical assessment and
intervention.
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Assessment of Parents
Screening for parental disorders or family characteristics that may impact children’s
adjustment and parental capacity to cooperate with treatment is an essential element of
assessment. Parental depression and substance abuse are specific disorders that, when present,
will substantially undermine parents’ abilities to provide assistance to their children in the
aftermath of abuse and are associated with re-referral to child protection authorities.
Fortunately, especially in the case of depression, effective treatments are available. When
necessary, therapists treating abused children should refer parents to appropriate intervention
programs or be able to provide the services as part of a comprehensive treatment plan.
Explaining the ways that these conditions interfere with helping children recover may be a
helpful strategy to overcome parental resistance to a focus on their problems since most nonoffending parents and some offending parents do have concern for their children’s welfare.
Level of parental distress regarding abuse of the child in sexual abuse cases has been
shown to be an important determinant of children’s emotional and behavioral status (Cohen &
Mannarino, 1998a; Hanson et al., 1992). Therefore, the impact on the parent of learning about
and coping with results of child maltreatment is important to address. In addition to children's
emotional needs, there may be system interventions including investigations, legal proceedings,
child placement, and disruption in living situations and arrangements that are a source of stress
for the parents. Problem solving and stress management strategies may be indicated to alleviate
distress that interferes with parental capacity to respond to their children and participate in other
interventions.
Level of belief and support about the abuse experience has been found to correlate with
children’s adjustment in sexual abuse cases and are typically a focus of intervention (Cohen &
Mannarino, 1998a; Morris et al., 1996). Whether these factors are important for physically
abused children has not been the specific subject of investigation. Treatments for physically
abused children have not generally required that parents acknowledge the abusiveness of the
behavior. In fact, some writers have recommended against an emphasis on labeling the
behavior. This is probably because in most cases of physical abuse in treatment contexts, the
children are living in the home with the abusive parent and both are participating in joint
treatments. However, some assessment of parental views about what happened, and the
wrongful or harmful nature of the behavior is likely to be relevant to treatment planning.
Offending parents or siblings, especially in the case of sexual abuse may suffer from a
variety of deficits that require specific interventions. In the case of physical abuse, these may be
assessed in terms of attitudes toward the use of violence and the repertoire of behavioral skills
parents possess for responding to child misbehavior. In sexual abuse cases, degree of
responsibility taken for the abuse, attitudes about the harmful consequences, skills deficits, and
empathy are frequent targets for treatment. In addition, certain pathologies, sexual deviance and
antisocial or psychopathic characteristics are predictive of risk to reoffend. Standards for
assessment methods for sexual offenders have been promulgated by the Association for the
Treatment of Sexual Abusers (2001) and may involve the use of psychophysiological
technologies such as the polygraph and penile plethysmography. Sexual offender treatment is
generally considered an area of specialty practice that requires highly specialized knowledge and
training.
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Use of Standardized Measures
Standardized assessment instruments can be very useful tools in the assessment of abused
children and their families. As the term implies, they provide a standardized and structured
approach to measuring problems commonly experienced by abused children, and can help
provide a more precise assessment of target problems. They also can be administered over time
to assess treatment progress and aid in clinical decision-making. Several instruments have been
developed specifically for measuring abuse-related problems and have been tested with abused
children. They are designed to evaluate problems frequently experienced by these children and
to be used specifically in cases of abuse. In addition, many general mental health measures that
are used with all sorts of child populations have been used successfully with abused children.
All of these instruments can be clinically valuable when assessing abused children and their
families. Standardized measures should be considered as part of any comprehensive clinical
assessment process. Examples of instruments that have been used successfully in child abuse
cases and can be recommended for use include:
Child Abuse Potential Inventory (Milner, 1986)
Child and Adolescent Functional Assessment Scale (Hodges, 1997)
Child Behavior Checklist (Achenbach, 1991)
Child Sexual Behavior Inventory (Friedrich, 1998a)
Children’s Impact of Traumatic Events Scale (Wolfe & Gentile, 1991)
Child’s Attitude towards Mother Scale (Hudson, 1982)
Child’s Attitude towards Father Scale (Hudson, 1982)
Fear Survey Schedule for Children–Revised (Ollendick, 1978)
Index of Self Esteem (Hudson, 1982)
Kovacs’ Children’s Depression Inventory (Kovacs, 1992)
Revised Children’s Manifest Anxiety Scale (Reynolds & Richmond, 1985)
Symptom Checklist-90-Revised (Derogatis, 1983)
Trauma Symptom Checklist for Children (Briere, 1996)
Trauma Symptom Inventory (Briere, 1995)
Obviously, this is not an exhaustive or comprehensive list of measures that can be useful in child
abuse cases. Rather, they are examples of measures that have been used successfully with
abused children and their families. Appropriate standardized measures should be selected
according to the problems to be assessed in any assessment.
Treatment Planning
A treatment plan should be based directly on the results of the assessment. It should
coincide with problems and needs that have been identified for the children, their parents, and
the family. Feedback and discussion of the results with family members are important
ingredients of the assessment process. They can also aid in generating cooperation with the
treatment plan and positive expectations for treatment. Clinicians should be able to explain and
support diagnoses and recommendations in every day language and by using examples. In this
way assessment becomes a first step in engagement in therapy. It also is important to be able to
highlight areas of competent functioning and strengths. These are the building blocks for growth
and successful therapies.
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The acceptability of a treatment plan may rest in part on the degree to which children and
families perceive that there is respect for their particular circumstances, background, and values.
As previously mentioned, cultural and religious factors can be especially relevant. For example,
while there is a clinical wisdom that openness and discussion about sexual abuse can help
ameliorate trauma symptoms, in some cultures a recommendation that a child participate in a
group or talk openly in the family or to friends about sensitive matters may conflict with cultural
expectations and place a child in worse circumstances. Family, religious, or cultural values that
are supportive of corporal punishment may conflict with treatment approaches that eschew these
methods. Families may prefer to seek treatment with providers or in settings where they believe
there will be greater understanding or appreciation of their cultural identity and values and where
they are more comfortable. Clinicians should inquire about these issues during the assessment
process and to the extent that families can be accommodated without compromising essential
treatment considerations, treatment plans may be more likely to be carried out.
The practicality of treatment plans is also important. It is not helpful to present families
with a long list of treatment recommendations that may overwhelm them and seem never ending.
Plans that call for services that are unavailable, require many sessions per week, or are beyond
the financial means of the family are not useful because it is unlikely they will be followed.
Many families where child maltreatment has occurred are poor or struggling in the first place,
and their financial circumstances may have been worsened by abuse-related systems
interventions. Maltreating families often lack organizational skills, tend to be socially isolated,
and may not have much experience with using resources outside the family. Triage, constructing
a plan with a reasonable number of recommended interventions, identification of specific
settings that offer the needed services, flexibility in scheduling appointments, and advocacy to
secure concrete assistance with transportation and child care may be necessary to implement a
treatment plan.
Summary of Assessment
In summary, assessment is the cornerstone of the treatment process. Without accurate,
comprehensive, and sophisticated assessment, followed by reasonable treatment planning,
interventions are likely to be misguided and ultimately ineffective. Assessment in abuse cases
should focus on, but not be limited to, problems known to be common among abused children.
The special issues surrounding abuse cases such as risk assessment, safety planning, and the
complicated familial and parent-child relationship issues that exist should be a part of the
assessment process. Assessment should result in an accurate portrayal of the functioning of the
abused child and their family within their cultural context. Treatment planning should target
these problems in a realistic way and apply the best treatments available to the revealed
problems.
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TREATMENT PROTOCOLS FOR CASES
OF SEXUAL AND PHYSICAL ABUSE
The 24 treatment approaches described in the following reference section were selected
based on the criteria described above. They target abuse consequences in children, problems of
parents or parent/child relationships significantly associated with maltreatment, or abusive
behaviors of parents. These approaches do not constitute an exhaustive or comprehensive list of
treatments that may be necessary or useful in child abuse cases. For example, pharmacological
interventions are not included although they may be helpful adjunctive treatments for children or
parents. Many parents will have substance abuse disorders or major depressive disorder, both of
which are risk factors for reabuse. There are well-established interventions for depression and
substance abuse that are not covered in these guidelines. In many cases children or parents will
suffer from comorbid psychiatric conditions (e.g., ADHD, conduct disorder, oppositional defiant
disorder, personality disorders) or live in environmental circumstances (e.g., poverty, inadequate
housing) that may need to be a focus of intervention but are not specific to child abuse.
The selected interventions are designed to reflect the array of abuse specific interventions
typically used or considered in cases of child maltreatment. In some cases particular program
models were chosen because they represent exemplary programs of the type and have been the
subject of evaluation or research (e.g., therapeutic childcare and intensive family intervention).
The various parenting interventions are presented because parenting classes or interventions are
routinely recommended or ordered in child maltreatment cases. Although it is likely that most of
the usual community-based parenting programs are not as intensive or empirically grounded as
the programs described in this document, treatments focused on parenting practices are a central
component of the treatment response to abuse situations. Most of the remainder of the
interventions were specifically developed to treat abuse-related conditions.
Each treatment protocol description consists of the following sections:
Brief Description
Theory and Rationale
Treatment Components
Treatment Manuals or Protocol Descriptions
Treatment Outcome Study References
Common Length of Treatment
Classification Rating
Treatments are divided into three sections:
I.
II.
III.
Child-Focused Interventions
Parent, Parent-Child, and Family Focused Interventions
Offender Focused Interventions
This reference section is provided for the purpose of assisting clinicians in selecting
treatment components that can be matched to concerns that are identified during the assessment
process. In many cases children and families will benefit by more than one protocol, including
treatments that are not included here. In a particular case, different practitioners may deliver
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different treatments to provide a comprehensive treatment approach to families. However, it is
assumed that the abuse-related problems and the needs of the abused children will be the clinical
priority and the primary focus of treatment. Whenever possible it is desirable that non-offending
parents participate in children’s therapy. Some treatment approaches include components
designed to strengthen the parent-child relationship. In other situations, it may be incorporated
into an abuse-focused treatment program as a separate component.
Treatment that is specifically directed at the parent’s abusive behavior may or may not be
relevant to treatment planning for the abused children depending on the clinical presentation and
family structural context. In cases of less serious physical abuse, children will often remain
living with the abusing parent, and treatment that includes a focus on the parent-child
relationship and parental disciplinary practices is essential. In other cases, children will be
separated from abusing or non-protective parents. Treatment for the parents will be required if
the child is to be returned to the home. However, the parents may not be available or
cooperative with treatment recommendations. In these cases, children should still be assessed
and treated for abuse consequences, regardless of whether the parents are involved.
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Child Focused Interventions
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Cognitive-Behavioral and Dynamic Play Therapy for Children with Sexual
Behavior Problems and Their Caregivers
Prepared by Barbara Bonner, Ph.D.
Brief Description:
These two group treatment approaches were designed for children ages 6 to 12 and their
caregivers who exhibit sexual behavior beyond normal child sexuality and that causes problems
in their functioning. One approach is based on the principles of cognitive behavioral therapy, and
the other is based on dynamic play therapy. They are designed to reduce the occurrence of
inappropriate and/or aggressive sexual behavior in children.
Theory and Rationale:
Children who have been maltreated sometimes develop sexual behavior problems. Two
theoretically different approaches to group treatment have been developed and tested. The two
approaches, cognitive-behavioral therapy and dynamic play therapy, are frequently used for
behavior problems in children, have evidence for effectiveness, and can be used in a wide range
of mental health settings. The principles of cognitive-behavior therapy and its use with children
have been well described in the literature (e.g., Meyers & Craighead, 1984). The behavioral
component is straightforwardly concerned with human behavior and broadly based on the
principles of learning theory. The cognitive aspect emphasizes the complex cognitions involved
in information processing in human beings, such as beliefs, attributions, decision-making
processes, and their influence on behavior. The cognitive-behavioral approach used in this
program relies on behavior modification principles for group management and incorporates
strategies directed at cognitive rules, decision making, impulse control, and education. It is
highly structured and uses a teaching-learning model.
The rationale for the use of dynamic play therapy is that children with sexual behavior
problems may be experiencing intense negative emotions stemming from sexual, physical and/or
emotional abuse, neglect, and/or other trauma (Friedrich, 1990; Friedrich & Luecke, 1988; Smith
& Israel, 1987). Inappropriate processing and expression of these feelings may result in sexual
behavior. Play therapy assumes that play is the child's natural medium for expression and is a
vehicle for emotional processing and behavior change. The spontaneous interactions combined
with the controlled conditions in a play therapy setting provide a means for achieving goals that
therapists have identified as critical in working with children with sexual behavior problems (Gil
& Johnson,1993). These goals include helping children gain insight into their own behavior;
increasing children's ability to observe and appreciate other people's feelings, needs, and rights;
helping children understand their needs and values, and to develop their own goals and internal
resources; increasing children's ability to meet their needs in socially appropriate ways; and
increasing children's connectedness to positive others and building internal strengths that support
future growth. The dynamic play therapy approach used in this program incorporates aspects of
client-centered and psychodynamic play therapies. The client-centered aspects help instill selfefficacy and self-worth in the participants. The psychodynamic aspects help ensure productive
interactions between group members and increased self-understanding or insight. Both
approaches have been found equally effective in reducing children’s sexual behavior problems at
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the two-year follow-up (Bonner, Walker, & Berliner, 2000). The treatments consist of twelve
once weekly sessions.
Treatment Components:
Cognitive-Behavioral Therapy
•
Acknowledgment of breaking sexual behavior rule(s).
•
Learning and applying Sexual Behavior Rules for children.
•
Impulse control through learning and applying the Turtle Technique (a stop and think
before acting strategy).
•
Receiving age-appropriate sex education.
•
Cognitive reframing to prevent reabuse of or by the child.
•
Weekly assessment of acquisition of information.
•
Positive reinforcement for appropriate behavior and participation in group exercises.
•
Caregiver participation in collateral group treatment that includes education regarding
age-appropriate sexual behavior in children, assisting children with applying the Sexual
Behavior Rules and Turtle Technique, child behavior management techniques, and rules
for supervision.
Dynamic Play Therapy
•
Reflection to increase child’s self understanding (insight).
•
Acceptance to convey positive regard for the child and improve the child’s self-esteem.
•
Interpretation to assist children in identifying and expressing feelings.
•
Facilitating group interaction to improve peer relationships.
•
Caregiver participation in collateral group treatment that uses acceptance, reflection, and
interpretation to process problems presented by the caregivers; encourages interaction
among the parents; and uses the group process/interaction as the modality of change.
Duration of Treatment:
12 sessions
Treatment Manual or Protocol Descriptions:
Bonner, B., Walker, C.E., & Berliner, L. (1999). Treatment manual for cognitivebehavioral group therapy for children with sexual behavior problems. National Clearinghouse
on Child Abuse and Neglect: Washington, DC. 1-800-394-3366.
Bonner, B., Walker, C.E., & Berliner, L. (1999). Treatment manual for cognitivebehavioral group treatment for parents/caregivers of children with sexual behavior problems.
National Clearinghouse on Child Abuse and Neglect: Washington, DC. 1-800-394-3366.
Bonner, B., Walker, C.E., & Berliner, L. (1999). Treatment manual for dynamic group
play therapy for children with sexual behavior problems and their parents/caregivers. National
Clearinghouse on Child Abuse and Neglect: Washington, DC. 1-800-394-3366.
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Treatment Outcome Study References:
Bonner, B., Walker, C.E., & Berliner, L. (2000). Final report. Children with sexual
behavior problems: Assessment and treatment. Grant No. 90-CA-1469. National Clearinghouse
on Child Abuse and Neglect: Washington, DC. 1-800-394-3366.
Classification Rating:
3
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Cognitive Processing Therapy (CPT)
Prepared by Patricia Resick, Ph.D. and Gretchen Clum Ph.D.
Brief Description:
Cognitive Processing Therapy (CPT) is a brief, structured, cognitive-behavioral treatment
designed to treat posttraumatic stress disorder (PTSD) and associated features such as
depression. CPT is a therapy consisting of exposure to the traumatic memory, training in
cognitive restructuring, and modules on topics that are most likely to be affected by rape and
other interpersonal trauma.
Theory and Rationale:
Exposure-based (Foa & Kozak, 1986) and cognitive therapies (McCann & Perlman,
1990) are often used to treat trauma victims. CPT combines both approaches with the cognitive
components tailored for rape victims, although treatment strategies can be modified for other
traumatic experiences. CPT has been developed to help trauma victims (1) understand how
thoughts and emotions are interconnected, (2) accept and integrate the traumatic experience as
an event that actually occurred and cannot be ignored or discarded, (3) experience fully the range
of emotions attached to the event, (4) analyze and confront maladaptive beliefs, and (5) explore
how prior experiences and beliefs both affected reactions and were affected by the trauma.
The goals of CPT are twofold. One goal is exposure to the traumatic memory. Although
exposure is important because it helps to activate the client’s fear-structure, it does not provide
direct corrective information regarding misattributions or maladaptive beliefs (Resick &
Schnicke, 1993). Therefore, a cognitive component is added to address these issues. The
cognitive component is based on the theory that traumatic experiences are often problematic
because the new information often does not fit into existing schemas. Without a way to
understand and categorize the experience, the strong emotions associated with traumatic
experiences are left unprocessed. In addition, when individuals encounter new information that
is inconsistent with preexisting beliefs or schemas, one of two things can occur: assimilation or
accommodation. Assimilation involves distortion of new information so that such information is
consistent with schemas, while accommodation involves altering schemas because of the new
discrepant information. Over-accommodation occurs when schemas are changed at an extreme
level as a result of the traumatic experience. Assimilation and over-accommodation are
problematic because they often lead to self-blame, guilt, manufactured emotions such as
embarrassment or shame, or dysfunctional cognitions. One goal of CPT is to help clients move
from using these strategies to using accommodation while processing cognitions related to the
traumatic experience. Outcome studies support CPT as a treatment for PTSD and PTSD-related
depression. In one clinical outcome study CPT in a group format was superior to wait list control
for both PTSD and depression at post-treatment and at a 6-month follow-up (Resick & Schnicke,
1992). CPT produces symptomatic relief within 12 treatment sessions.
Treatment Components:
•
•
Information and education regarding symptoms of PTSD, information processing theory.
Explore meaning of event, client writes impact statement.
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•
•
•
•
•
•
•
Identification of thoughts and feelings, Antecedents-Behavior-Consequences sheets.
Discussion of self-blame and labeling of event.
Exposure – client writes description (account) of event, reads aloud in session, process
affect.
Identification of stuck points (conflicting beliefs or strong negative beliefs that create
unpleasant emotions or unhealthy behavior) .
Challenging Questions, Faulty Thinking Patterns, and Challenging Beliefs Worksheet
(incorporates A-B-C sheets, challenging questions and faulty thinking patterns).
Five individual modules covering issues of safety, trust, power/control, esteem and
intimacy related to oneself and others.
Explore meaning of event, client writes second impact statement at end of therapy.
Duration of Treatment:
12-16 sessions
Treatment Manuals or Protocol Descriptions:
Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims:
A treatment manual. Newbury Park, CA: Sage Publications.
Calhoun, K. S., & Resick, P. A. (1993). Treatment of PTSD in rape victims. In D. H.
Barlow (Ed.), Clinical handbook of psychological disorders, (pp. 48-98). New York: Guilford
Press.
Treatment Outcome Study References:
Ellis, L. F., Black, L. D., & Resick, P. A. (1992). Cognitive-behavioral treatment
approaches for victims of crime. In P. A. Keller & S. R. Heyman (Eds.), Innovations in clinical
practice: A source book (11, pp. 23-38). Sarasota, FL: Professional Resource Exchange.
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault
victims. Journal of Consulting and Clinical Psychology, 60(5), 748-756.
Resick, P. A. (1992). Cognitive treatment of crime-related post-traumatic stress disorder.
In R. D. Peters, R. J. McMahon, & V. L. Quinsey (Eds.), Aggression and violence throughout
the life span (pp. 171-191). Newbury Park, CA: Sage Publications.
Classification Rating:
3
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Eye Movement Desensitization and Reprocessing (EMDR)
Prepared by Claude Chemtob, Ph.D.
Brief Description:
EMDR is a multi-component therapeutic procedure for traumatic memories and for posttraumatic stress disorder (PTSD) that purports to restart and facilitate blocked processing of the
traumatic memory, promote more adaptive cognitions regarding the trauma, and to install
alternate positive cognitions, coping strategies, and adaptive behaviors.
Theory and Rationale:
EMDR theory is grounded in adaptive cognitive network theories of learning and
emotion (Lang,1977; Bower, 1981) and in Piagetian views of learning in which assimilation and
accommodation are seen as key processes in the adaptive efforts of human beings. Shapiro
(1995) has proposed an “accelerated information processing” model to account for traumatic
memories and for their resolution through EMDR which draws on these traditions. The model is
based on a number of key propositions. First, traumatic memories are not fully assimilated into
the broader cognitive network which demarcates a person’s experience; that is they remain
partially associatively isolated from the person’s larger life experience. Because such memories
are not fully assimilated within the person’s pre-existing cognitive schemas, they exert a
disequilibrating influence on subsequent information processing. Second, traumatization
interferes with psychological and biological processes that normally promote assimilation and
accommodation of memories. Trauma memories contain a number of semantic and affective
distortions reflecting this partial dissociation from the broader semantic-cognitive network.
Storage in this unaccommodated form can impact other processing negatively, leading to
distortions in perception, feeling, and response. Third, EMDR theory proposes that there exists
within people an intrinsic self-healing mechanism that is activated by the EMDR procedure. The
activation serves to dynamically restart the integration of trauma memories and their assimilation
into a normalized form. This inherent information processing mechanism is hypothesized to
account for extremely rapid treatment related changes. Fourth, EMDR theory extends other
information processing theories of PTSD by specifically describing the importance of selfrepresentations in the encoding of trauma memories. Fifth, EMDR theory emphasizes the
importance of systematic skill-building to compensate for the trauma’s interference with the
acquisition of appropriate competencies. While some have proposed that EMDR’s effects are
accounted for by its exposure component, traditional theories of exposure do not account for the
efficacy of the brief duration of the exposure in EMDR. Additional research on EMDR’s mode
of action is needed.
Adult treatment outcome research indicates that EMDR is efficacious for PTSD, although
substantial questions remain regarding its actual mode of action (Chemtob, Tolin, Van Der Kolk,
and Pitman, 2000). There are three controlled studies of EMDR with traumatized children or
adolescents. All three suggest EMDR is efficacious. Three sessions of EMDR were shown to be
effective for disaster-related PTSD compared to a wait list condition in treatment resistant
children exposed to a natural disaster (Chemtob, Nakashima, & Carlson, 2002). Two studies of
children/young adults with various clinical problems compared two or three sessions of EMDR
added to routine care to routine care or to a non-specific intervention. Findings showed that
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EMDR produced superior results on measures of memory-related distress as well as other
outcomes
Treatment Components:
History and Treatment Planning
•
Evaluation of child readiness, barriers to treatment, dysfunctional behaviors, symptoms,
and illness characteristics.
•
Development of a treatment plan that addresses trauma-specific memories as well as
present reminders of the traumatic event and identifies remedial skills needed for the
patient's future use. A key decision is whether to address trauma-related memories in
caretakers.
Preparation
•
Establish an appropriate treatment relationship with the child and caretaker.
•
Provide education about trauma and to inform the child and caretaker of the rationale
behind EMDR.
•
Teach child and caretaker specific coping skills for processing trauma-related material as
it emerges.
Assessment
•
The child identifies (a) a distressing image in memory, (b) an associated negative
cognition, (c) an alternate positive cognition, (d) rates the validity of the positive
cognition (VoC), (e) identifies the emotions associated with the traumatic memory, (f)
rating the subjective level (or units) of distress (SUD), and (g) identifies trauma-related
physical sensations and their bodily location (e.g., a flutter in the stomach). In addition,
the child is asked to identify a “safe place” in imagination. This “safe place” is used to
establish feelings of safety at the beginning of each session and to reach closure at the
end of each session.
Desensitization and Reprocessing
•
After imagining the “safe place” identified previously, the child holds in mind the
distressing image, the negative cognition, and the trauma-related body sensations while
the clinician moves his/her fingers back and forth and the child tracks the fingers with
his/her eyes.
•
After approximately twenty back-and-forth eye movements, the clinician stops and asks
the child to “let go” of the memory, take a deep breath, and report changes in the image,
bodily sensations, emotions, or thoughts about the self.
Installation of Positive Cognition
•
Once the SUD rating has been reduced as far as possible toward zero (no discomfort), the
positive cognition is again assessed using the VoC scale. The child is instructed to think
of the target image while holding in mind the positive cognition.
•
Another set of eye movements is performed, followed by another assessment of the
validity of the positive cognition.
•
This cycle is repeated until the VoC rating rises as far as possible
-40-
•
Specific coping skills designed to deal with past memories and present emotions, as well
as optimal behavioral responses to future situations.
Body Scan
•
If a check with the child reveals any signs of residual physical tension or discomfort, the
child is instructed to attend to the physical sensations while additional sets of eye
movements are performed.
Closure
•
Prepare the child for leaving each session; techniques such as relaxation or visualization
are occasionally used.
Re-evaluation
•
Each subsequent session incorporates an assessment of whether treatment goals have
been reached and maintained. Trauma-related material that has emerged since the last
session is addressed.
Duration of Treatment:
2-3 sessions
Treatment Manual or Protocol Descriptions:
Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles,
protocols, and procedures. New York: Guilford.
Greenwald, R. (1993). Using EMDR with children. Pacific Grove, CA: EMDR Institute.
Chemtob, C.M. (1995). Study protocol for treating children with hurricane-related
PTSD using EMDR (unpublished study protocol). 1132 Bishop Street, Suite 307, Honolulu,
Hawaii 96813.
Treatment Outcome Study References:
Chemtob, C.M., Nakashima, J., & Carlson, J.G. (2002). Brief Treatment for Elementary
School Children with Disaster-related posttraumatic stress disorder: A field study. Journal of
Clinical Psychology, 58(1), 99-112.
Scheck, M. M., Schaeffer, J. A., & Gilette, C. S. (1998). Brief psychological intervention
with traumatized young women: The efficacy of eye movement desensitization and reprocessing.
Journal of Traumatic Stress, 11, 25-44.
Soberman, G. S., Greenwald, R., & Rule, D. L. (in press). A controlled study of eye
movement desensitization and reprocessing (EMDR) for boys with conduct problems. Journal
of Aggression, Maltreatment, and Trauma.
-41-
Puffer, M. K., Greenwald, R., & Elrod, D. E. (1998). A single session EMDR study with
twenty traumatized children and adolescents. Traumatology, 3(2),
http://www.fsu.edu/~trauma/v3i2art6.html.
Classification Rating:
3
-42-
Individual Child and Parent Physical Abuse-focused
Cognitive-Behavioral Treatment
Prepared by David Kolko, Ph.D.
Brief Description:
This treatment is a cognitive-behavioral intervention for children and physically abusive
parents that targets beliefs and attributions about abuse and violence, and teaches skills to
enhance emotional control and reduce violent behavior.
Theory and Rationale:
Cognitive-behavioral treatments based on the application of social learning principles
with their emphasis upon reciprocal influences between parents and children are designed to
alter the expression of appropriate or prosocial and inappropriate or deviant behavior.
Interventions based on the social-situational model have emphasized instruction and training in
new skills in various domains that relate to cognitive, affective, and behavioral development. In
working with physically abusive families, such techniques have been directed toward enhancing
non-violent discipline, anger control or stress management, and contingency management (see
Kolko, 1996a; Kolko, 1996b; Wolfe & Wekerle, 1993). Cognitive-behavioral treatments (CBT)
have reported various improvements in parent and child behaviors (e.g., Davis & Fantuzzo,
1989; Whiteman et al., 1987; Wolfe et al., 1988). Children and parents received separate
therapists who implement parallel protocols based upon social learning principles designed to
address their cognitive, affective, and behavioral-social repertoires (e.g.,Walker, Bonner, &
Kaufman, 1988; Wolfe et al., 1981). Treatment is directed toward teaching intrapersonal and
interpersonal skills, as most CBT studies have targeted one of these domains (see Wolfe &
Wekerle, 1993). Several technical materials were adapted for this protocol (e.g., Feindler &
Ecton, 1986; Fleischman, Horne, & Arthur, 1983; Wilson, Cameron, Jaffe, & Wolfe, 1986;
Walker et al., 1988; Wolfe et al., 1981).
Treatment Components:
Child:
•
Identification of views of family stressors and violence.
•
Teaching coping and self-control skills training (e.g., safety/support planning,
relaxation).
•
Training in interpersonal effectiveness skills to enhance social competence (e.g., using
social supports, social skills, and assertion).
•
Specific instructions regarding skill use, role-playing exercises, performance feedback,
and home practice exercises.
Parent:
•
Identification of views on violence and physical punishment, attributional style and
expectations.
•
Self-control (e.g., anger-control, cognitive coping).
•
Contingency management (e.g., attention, reinforcement, time-out).
-43-
•
Specific instructions regarding skill use, role-playing exercises, performance feedback,
and home practice exercises.
Duration of Treatment:
12-16 sessions
Treatment Manuals or Protocol Descriptions:
Kolko, D.J., & Swenson, C.C. (2002). Assessing and treating physically abused children
and their families: A cognitive-behavioral approach. Thousand Oaks, CA: Sage Publications.
Swenson, C.C. & Kolko, D.J. (2000). Long-term management of the developmental
consequences of child physical abuse. In R. Reece (Ed.). The treatment of child abuse.
Baltimore, MD: Johns Hopkins University Press.
Treatment Outcome Study References:
Kolko, D.J. (1996) Individual cognitive behavioral therapy and family therapy for
physically abused children and their offending parents: A comparison of clinical outcomes.
Child Maltreatment, 1, 322-342.
Classification Rating:
3
-44-
Resilient Peer Training Intervention
Prepared by John Fantuzzo, Ph.D.
Brief Description:
This is a school-based intervention for young abused children that is based on an
ecological model and uses competent peers and parent helpers to increase children’s social
competence.
Theory and Rationale:
Resilient Peer Training (RPT) intervention is a preschool, classroom-based intervention
developed for maltreated children at higher than average risk for maladaptive social functioning.
Guided by Fantuzzo’s overall Resiliency, Partnership-Directed approach to intervention
(Fantuzzo & Mohr, 2000), RPT is designed to enhance the development of social competencies
for vulnerable children by capitalizing on the strengths of resilient peers and the natural support
provided by teachers and parent volunteers in a therapeutic preschool or Head Start classroom
environment. A number of studies have been conducted to evaluate the effectiveness of the RPT
intervention for social isolated, low-income preschool children, who have been maltreated
(Fantuzzo, et al., 1997). These randomized field tests supported the effectiveness of the RPT
intervention. Socially withdrawn maltreated children showed a significant increase in positive
interactive peer play behavior and a decrease in solitary play behavior as a result of the RPT
Intervention. Treatment gains in observed social interactions were validated by teacher and
parent ratings of social functioning. Children who received RPT were found to exhibit
significantly higher self-control and interpersonal skills and interactive play. Treatment children
also showed significantly fewer incidences of behavior problems than children in the control
condition. Additionally, data indicated that the RPT interventions across preschool programs and
across studies were implemented with integrity (i.e., treatment carried out as planned at a 90%
level or greater) and the evaluation team received a 100% rate of cooperation from participating
preschool teachers and support staff.
Treatment Components:
•
•
•
•
Selection of a resilient peer (Play Buddy) to pair with a child manifesting peer problems
(Play Partner).
Working with teachers to establish Play Corners in the natural classrooms for dyads to
play with minimal distractions. Identifying and training parent volunteers (Play
Supporters) from the local preschool setting to support positive play interactions between
Play Buddies and Play Partners.
Daily RPT intervention sessions consisting of a 20-minute play session between the Play
Buddy and the Play Partner.
Observation by the Play Supporter who makes supportive comments at the end of the
play session.
Duration of Treatment:
20 play sessions over 8 week period, with booster and follow-up sessions as needed
-45-
Treatment Manuals or Protocol Descriptions:
Fantuzzo, J., Weiss, A., & Coolahan, K. (1998). Community-based partnership-directed
research: Actualizing community strengths to treat victims of physical abuse and neglect. In R.J.
Lutzker (ed.) Child abuse: A handbook of theory, research, and treatment. (pp. 213-238) New
York, NY: Pergamon Press.
Treatment Outcome Study Reference:
Fantuzzo, J., Sutton-Smith, B., Atkins, M., & Meyers, R. (1996) Community-based
resilient peer treatment of withdrawn maltreated preschool children. Journal of Clinical and
Consulting Psychology, 64, 1377-1368.
Classification Rating:
3
-46-
Therapeutic Child Development Program
Prepared by Laura Sheehan, M.A.
Brief Description:
This treatment is a milieu based intervention for maltreated preschool children that seeks
to reduce risk factors and enhance protective factors by providing children with positive
nurturing interactions with adults and a consistent, safe, monitored environment.
Theory and Rationale:
The therapeutic child development approach is based on research by expert child
practitioners and scientists showing that early life experiences and brain development affect
later-life functioning. Early maltreatment can alter or stunt brain development (DeBellis, et al,
1999; Perry & Pollard, 1998) and often occurs in the context of disrupted attachment (Cicchetti
& Barnett, 1991). Because the most active and critical time of brain development occurs during
the first 33 months (9 months’ gestation, plus 24 months), and because emotional behavior and
impulse control require practice and develop in the context of an attachment relationship to a
caregiver, the program treats children at the earliest period of development - birth to five years.
This type of program is usually recommended when there are significant concerns about parental
capacity to respond appropriately to their young children or where the children are exhibiting
substantial developmental lags and an intensive exposure to an alternative environment is
considered necessary. It is designed to develop empathy and emotional attachment to others, to
learn to control and balance feelings, especially those that can be destructive, to develop capacity
for cognitive processes, such as problem solving, and to learn the interactive skills necessary to
form other secure relationships. A central mechanism for creating protective factors is providing
emotionally attuned primary caregivers that create a growth-promoting environment and help
children form emotional attachments to caregivers. Children attend a milieu-based program
during the day and parents are provided with some educational and supportive services. In a
long-term follow-up, treated children were significantly less aggressive, had fewer internalizing
behavior problems, were less frequently arrested for violent and non-violent crimes, and were
less often identified as violent by caregivers (Moore, Armsden, & Gogerty, 1998).
Treatment Components:
•
•
•
•
•
•
•
•
•
•
Transportation of child to and from the program each day.
Treatment milieu environment of 9 to 15 children, depending on age of child.
Emotionally-attuned and responsive caregivers interacting with children.
Nutritious meals three times a day.
Healthcare monitoring.
Developmental therapies as needed; e.g., physical therapy, special education, speech
therapy.
Case management.
Monitoring of child and family for abuse and neglect, parental substance abuse,
compliance with court ordered conditions.
Parent education and parent support groups.
Applied parenting instruction.
-47-
Duration of Treatment:
Variable, can be many months or even years.
Treatment Manuals or Protocol Descriptions:
Childhaven, Inc. (undated). Childhaven Therapeutic Child Development Manual.
Seattle, WA: Author.
Treatment Outcome Study References:
Moore, E., Armsden, G., & Gogerty, P.L. (1998). A twelve-year follow-up study of
maltreated and at-risk children who received early therapeutic care. Child Maltreatment, 3, 316.
Classification Rating:
3
-48-
Trauma-focused Cognitive-Behavioral Therapy (CBT)
Prepared by Judy Cohen, M.D. and Esther Deblinger, Ph.D.
Brief Description:
Trauma-focused cognitive behavioral therapy, an intervention based on learning and
cognitive theories, is designed to reduce children’s negative emotional and behavioral responses
and correct maladaptive beliefs and attributions related to the abusive experiences. It also aims to
provide support and skills to help nonoffending parents cope effectively with their own
emotional distress and optimally respond to their children.
Theory and Rationale:
Cognitive-behavioral therapy (CBT) is based on the premise that symptoms develop and
are maintained, at least in part, by conditioned and learned behavioral responses as well as
maladaptive cognitions (Brewin, 1989). The model emphasizes the interdependence of thoughts,
behaviors, feelings as well as physiological responses. Thus, interventions designed to target
any one of these areas of functioning are expected to indirectly impact on adjustment in the other
areas of functioning as well. Treatment plans are based on comprehensive assessments and are
individually tailored to address the clients’ specific needs. The rationales for the use of CBT
interventions are full explained to clients so that they can be active participants in developing
and applying interventions in session and at home.
CBT has had demonstrated efficacy in addressing symptoms such as depression, anxiety
and panic attacks in adults and children (Lipsey & Wilson, 1993; Weisz, Weiss, Han, Granger, &
Moreton, 1995). CBT and behavioral interventions are the treatments of choice for behavior
problems in children (Weiss & Weisz, 1995). Trauma-focused CBT was initially developed for
adult survivors of trauma and has been proven effective for PTSD symptoms in studies with
adults (Rothbaum, et al., 2000). The success of CBT in treating these groups led to the
adaptation of trauma-focused CBT for children and adolescents. The treatment focuses on
conditioned emotional associations to memories and reminders of the trauma, distorted
cognitions about the event(s), and negative attributions about self, others and the world.
Nonoffending parents are included in the treatment process to enhance support for the child,
reduce parental distress, and teach appropriate strategies to manage child behavioral reactions.
In the latter stages of therapy, family sessions that include siblings may also be conducted to
enhance communication. Trauma-focused CBT has been proven effective for children exposed
to a variety of traumatic events and has received the strongest empirical support from studies
with abused children (American Academy of Child and Adolescent Psychiatry, 1998). It has
been used in individual, family, and group therapy and in office-based and school-based settings.
Treatment Components:
•
•
•
Psychoeducation about child abuse, typical reactions, safety skills and healthy sexuality.
Gradual exposure techniques including verbal, written and/or symbolic recounting (i.e.
utilizing dolls, puppets, etc.) of abusive event(s).
Cognitive reframing consisting of exploration and correction of inaccurate attributions
about the cause of, responsibility for, and results of the abusive experience(s).
-49-
•
•
•
•
Stress management techniques such as focused breathing and muscle relaxation exercise,
thought stopping, though replacement, and cognitive therapy interventions.
Parental participation in parallel or conjoint treatment including psychoeducation,
gradual exposure, anxiety management and correction of cognitive distortions.
Parental instruction in child behavior management strategies.
Family work to enhance communication and create opportunities for therapeutic
discussion regarding the abuse.
Duration of Treatment:
12-16 sessions
Treatment Manuals or Protocol Descriptions:
Deblinger, E., & Heflin, A.H. (1996). Treatment for sexually abused children and their
non-offending parents: A cognitive-behavioral approach. Thousand Oaks, CA: Sage.
Cohen, J.A., Mannarino, A.P. (1993). A treatment model for sexually abused
preschoolers. Journal of Interpersonal Violence, 8, 115-131.
Treatment Outcome Study References:
Berliner, L. & Saunders, B.E. (1996). Treating fear and anxiety in sexually abused
children: Results of a controlled 2-year follow-up study. Child Maltreatment, 1(4), 294-309.
Celano, M., Hazzard, A., Webb, C., McCall, C. (1996). Treatment of traumagenic
beliefs among sexually abused girls and their mothers: An evaluation study. Journal of
Abnormal Child Psychology, 24, 1-16.
Cohen, J.A., & Mannarino, A.P. (1996). A treatment outcome study for sexually abused
pre-school children: Initial findings. Journal of the American Academy of Child and Adolescent
Psychiatry, 35, 42-50.
Cohen, J.A., & Mannarino, A.P. (1997). A treatment study of sexually abused preschool
children: Outcome during a one year follow-up. Journal of the Academy of Child and
Adolescent Psychiatry, 36(9), 1228-1235.
Cohen, J.A., & Mannarino, A.P. (1998). Interventions for sexually abused children:
Initial treatment findings. Child Maltreatment, 3, 17-26.
Deblinger, E., McLeer, S. V. & Henry, D. (1990). Cognitive behavioral treatment for
sexually abused children suffering post-traumatic stress: Preliminary findings. Journal of the
American Academy of Child and Adolescent Psychiatry, 19, 747-752.
Deblinger, E., Lippmann, J., & Steer, R. (1996) Sexually abused children suffering
posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1, 310321.
-50-
Stauffer, L. & Deblinger, E. (1996). Cognitive behavioral groups for nonoffending
mothers and their young sexually abused children: a preliminary treatment outcome study. Child
Maltreatment, 1(1), 65-76.
Deblinger, E., Steer, R.A., & Lippmann, J. (1999). Two year follow-up study of
cognitive behavioral therapy for sexually abused children suffering post-traumatic stress
symptoms. Child Abuse & Neglect, 23(12), 1371-1378.
Classification Rating:
1
-51-
Trauma-focused Integrative-Eclectic Therapy (IET)
Prepared by William Friedrich, Ph.D.
Brief Description:
IET is a psychosocial intervention based on data suggesting that persistent effects of
trauma and maltreatment are best understood as a function of both the child and the child’s
relationships and living context. It is designed to increase safety in the home, enhance the
quality of the parent-child relationship, and assist the child or teenager in the acquisition of more
accurate self-perceptions and coping strategies.
Theory and Rationale:
Integrative-eclectic therapy (IET) is based on a number of principles from developmental
psychopathology (Cicchetti & Carlson, 1989). The first is that the child is embedded in the
family context (Kegan, 1982), and that the security of parent-child attachment is a key to the
child’s adaptive functioning and resilience in the face of adversity (Egeland, Jacobvitz, &
Sroufe, 1988). A second principle is that maltreatment experiences are dysregulating (Siegel,
1999) and are directly related to a range of symptoms that typically need to be addressed.
Finally, the developing organism is increasingly an observer of self (Harter, 1986), and accuracy
of self-perception will facilitate long-term coping and allow for necessary psychologicalmindedness to bring to future situations (Calverly, Fischer, & Ayoub, 1994).
IET is grounded in a substantial body of research (Friedrich, 1995). For example, it
draws on the initial portion of Parent-Child Interaction Therapy that is designed to enhance the
nonabusive parent-child relationship via the utilization of child-directed play activities
(Hembree-Kigin & McNeil, 1995). A number of attachment related issues can be addressed
including sensitive parenting, commitment to the child’s welfare, the reduction of intrusive
parenting, and the increase in positive attention. Sensitive parenting is also reflected in the
safety of the child’s house, and the accuracy with which the parent views the child. In addition,
parents of maltreated children are typically multiply entrapped in their family of origin as well as
with helping professionals and court and social services.
Symptoms of dysregulation have been effectively treated by cognitive behavior therapy
(CBT) that combines exposure and the instruction in relaxation or imagery skills. IET goes
beyond most CBT-based programs in that the parent-child relationship also is addressed along
both cognitive and relational dimensions. (Please note: Some CBT programs for abused children
also include interventions for parent-child relationships, e.g., Deblinger & Heflin, 1996). In
addition, behavioral strategies can be effectively used to address other symptoms of
dysregulation, including sexual behavior problems, and anger. Sensitivity to the intervention
strategy also is needed so that the child does not become more agitated and/or out of control with
the treatment. Finally, the accuracy of both the child’s and parent’s self-perception is also a
developmentally related construct that assumes greater importance, as the individual grows
older. The intervention is designed to address issues of shame, self-blame, and potency along
with an understanding of self-in-relationships. IET was developed in work with disadvantaged
families that were both therapy illiterate and avoidant; it is goal-based in order to make therapy
more understandable and reinforcing. Treatment length is variable.
-52-
Treatment Components:
•
•
•
•
•
•
•
•
•
•
Identify all parties that are involved in the family’s life and develop a coordinated
treatment plan.
Identify specific goals in the areas of parent-child attachment and safety in the home that
must be addressed in the course of treatment.
Set treatment goals in the areas of safety and parent-child connection.
Address issues of safety that further trigger the child and concretely help the parent show
commitment to the child’s welfare.
Enhance the quality of the parent-child relationship via child-directed interaction.
Correct the inaccurate perceptions the parent has of the child.
Help the parent to realize how their own disadvantaged upbringing influences their
parenting and address as possible.
Help child and parent to realize links between thoughts, feelings, and behaviors.
Teach alternate strategies of coping including relaxation, imagery and self-talk.
Once the parent-child relationship has improved, teach developmentally appropriate
behavior management strategies.
Duration of Treatment:
Variable, generally over a period of months
Treatment Manuals or Protocol Descriptions:
Friedrich, W.N. (1995). Psychotherapy with sexually abused boys. Thousand Oaks, CA:
Sage.
Friedrich, W. N. (1998). Treating sexual behavior problems in children: A treatment
manual. Available from the author at the Mayo Clinic, Department of Psychiatry and
Psychology, Rochester, MN 55905.
Treatment Outcome Research References:
Friedrich, W. N., Luecke, W. J., Beilke, R. L., & Place, V. (1992). Group treatment of
sexually abused boys: An agency study. Journal of Interpersonal Violence, 7, 396-409.
Classification Rating:
3
-53-
Trauma-focused Play Therapy
Prepared by Eliana Gil, Ph.D.
Brief Description:
This treatment is a psychotherapeutic intervention that uses play as a mechanism for
allowing abused children to use symbols (toys) to externalize their internal world, project their
thoughts and feelings, and process potentially overwhelming emotional and cognitive material
from a safe distance.
Theory and Rationale:
Play has been chronicled as a vehicle to help children with tasks such as mastery,
problem-solving and conflict resolution, communication, affective expression, cognitive
stretching, developmental strides, and relational issues (Schaefer, 1993). Therapeutic play is
used by trained professionals as a tool for assisting children with a range of psychosocial
problems. Guided by a strong belief in the curative qualities of play, trauma-focused play
therapists carefully select toys that will allow the child to symbolize or literally recreate elements
of the trauma experience so that it may be processed and integrated. Therapeutic play can
therefore be considered the child’s natural way of experiencing gradual exposure, a cognitivebehavioral strategy for addressing anxiety or fear. Through post-traumatic play, traumatized
children expose themselves to the story, scenario, or behavioral sequence they may fear, avoid or
misunderstand (Gil, 1991). Through this external reconstruction they are able to contain and
manage otherwise overwhelming and fragmented affect and cognition. Trauma-focused play
often gives way to affective discharge, cognitive evaluation, and frees up psychic or emotional
energy that is bound by traumatic memories. The trauma-focused play therapist witnesses the
child’s reality, provides unconditional acceptance of the child’s feelings, thoughts, and reactions,
challenges cognitive distortions and promotes empowerment and resiliency.
Treatment Components:
•
•
•
•
•
•
•
•
Selection and display of appropriate toys and miniatures based on the particular child’s
traumatic situation.
Giving therapeutic permission and encouragement to move at the child’s own pace.
Observation and recording of the child’s post-trauma play and accompanying affect.
Reflective commenting on the child’s post-trauma play or therapeutic questions that ask
the child to expand on narrative already provided of play.
Assisting with clarification, processing of idiosyncratic meaning, affect discharge,
sequential organization and integrating of difficult cognitions and affect.
Helping the child manage anxiety, develop new coping strategies, and identify external
resources.
Providing parental support and education as well as guidelines for observing and
participating in child’s every day play without over-interpreting and/or becoming
intrusive.
Collateral individual therapy for parents, particularly if prior abuse issues interfere with
current abilities to address their child’s needs for safety and support.
-54-
Duration of Treatment:
Variable, generally over a period of months
Treatment Manual or Protocol Descriptions:
Gil, E. (1991). The Healing Power of Play. New York: Guilford Press
Gil, E. (1996). Treating Abused Adolescents. New York: Guilford Press.
Gil, E. (1998). Essentials of Play Therapy with Abused Children. New York: Guilford
Press.
Treatment Outcome Research References:
None
Classification Rating:
4
-55-
Family, Parent-Child and ParentFocused Interventions
-56-
Attachment-Trauma Therapy
Prepared by Beverly James, MSW and Karen Sitterle, Ph.D.
Brief Description:
This treatment is a multidimensional intervention with the primary goal of creating or
restoring a secure primary attachment relationship for the child and caretaker using positive
affective and sensori-motor interactions designed to establish the experience of safety and
attunement within with matrix the child and parent are helped to process the traumatic event.
Theory and Rationale:
Attachment and trauma problems are often interwoven for children in instances such as
the loss of a primary attachment figure, experiencing or witnessing violence, or when a
traumatizing experience results in serious disturbance in the attachment relationship. Research
and clinical experience demonstrate that the quality of the attachment relationship influences all
aspects of a child’s development (Winnicott, 1960; Bowlby, 1969; Ainsworth, 1973; Stern,
2000; Zeanah & Scheeringa, 1996). Abnormal developmental attachment patterns can result
from significant problems in the infant-parent relationships (Greenspan and Lieberman, 1988).
Trauma can cause developmental problems as well (Pynoos, Steinberg, & Wraith, 1995). The
combined impact of attachment-trauma problems often produce serious developmental injuries
in forming and maintaining interpersonal relationships (Crittenden, 1988; Lieberman & Pawl,
1988; Cicchetti, 1989), in affect regulation (Schore, 1994; Terr, 1994; Crittenden & Ainsworth,
1989; Perry, 1995), neurological and structural brain development (Perry, 1995; Schore, 1994),
language development (Greenspan & Lieberman, 1988; Cicchetti, 1989), language and
emotional language usage (Cicchetti, 1989; Chicchetti, Cummings, Greenberg, & Marvin, 1990;
Kobac, 1993; Schore, 1994).
Attachment-trauma therapy is based on the premise that children need to experience
safety in an attachment relationship in order to adequately cope with traumatizing experiences
(Fraiberg, 1975; James, 1989a: James, 1989b; Pearce & Pezzot-Pearce, 1997). The need for
stimulation of the affective and motor system in facilitating a positive attachment relationship is
supported by neurophysiological research (Perry, 1995) and in research with very young children
who witness family violence (Osofsky & Fenichel, 1994; Gaensbauer & Siegel, 1995).
Children’s symptoms of avoidance, dysregulated affect, automatic response to perceived threat,
and dysfunctional behavioral adaptations create barriers to formation of new attachment
relationships and from coping with trauma (James, 1994; Hughes, 1997). Barriers for parents in
forming a secure attachment with the child include fear, ignorance of attachment-trauma
dynamics, disappointment and despair related to the child, and their own pathological behaviors
(Herman, 1992; James, 1994). Therapy is designed to build a foundation of pleasure in the
relationship, create emotional and physical attunement, promote emotional competency, reduce
stress, increase communication and trust, increase awareness and insight, help children master
traumatic experiences, enhance authentic communication and generally strengthen the
attachment bond. Treatment length is variable.
-57-
Treatment Components:
•
•
•
•
•
•
•
•
•
•
Psychoeducation about attachment, development, trauma, adaptive and survival
behaviors.
Directed positive affective and sensori-motor activities between caregiver and child in
session and at home.
Use of drama, metaphor, and movement interventions to identify, differentiate, manage,
increase and practice a range of emotional expression.
Stress management and focusing techniques including yoga, deep breathing, muscle
relaxation, and imagery.
Cognitive and expressive arts interventions.
Family play and behavioral interventions.
Focused trauma-loss work using play therapy techniques in small manageable pieces.
Family ritual and commemoration interventions when a relationship has been lost.
Family discussions to celebrate accomplishments, anticipate future problems, identify
tools to handle them, and plan for regular check-ups.
Graduation ceremony.
Duration of Treatment:
Variable, generally over a period of months
Treatment Manuals or Protocol Descriptions:
James, B. (1994). Handbook for treating attachment-trauma problems in children. New
York, NY: Free Press/Simon & Schuster.
Treatment Outcome Study References:
None
Classification Rating:
4
-58-
Behavioral Parent Training Interventions for
Conduct-Disordered Children
Prepared by Elizabeth Brestan, Ph.D. and Holly Payne
Brief Description:
Behavioral parent training encompasses several treatment protocols that target behaviordisordered children and their families. They typically use a short-term behavioral intervention
and usually involve teaching parents skills based upon behavior theory designed to increase child
compliance, decrease child disruptive behavior, and minimize coercive interactions between
parent and child at home and in other settings.
Theory and Rationale:
Maltreated children often display disruptive behaviors that may be the result of
maltreatment or stem from disordered family interactions (Hersen & Ammerman, 1990; Lutzker,
Van Hasselt, Bigelow, Greene, & Kessler, 1998; Stern & Azar, 1998) Child behavior problems
may contribute to risk for maltreatment as well (Hersen & Ammerman, 1990; Lutzker, et al.,
1998). Treatments designed to change parenting practices are, therefore, considered risk
reduction strategies as well as responses to the children’s behavior problems. These interventions
differ from didactic “parenting” classes in that they are based on established principles of
behavior change and involve teaching skills in addition to conveying information.
Approximately 40% of such interventions are manualized treatments and a recent review of
effective psychosocial treatments for conduct-disordered children found several of these
treatment “packages” to have empirical support for their efficacy (Brestan & Eyberg, 1998). A
number of different approaches have been developed and tested.
G. R. Patterson’s Living With Children. Parent training programs based on Patterson
and Gullion’s (1968) manual Living with Children rely on operant principles of behavior change
and teach parents to monitor targeted deviant behaviors, monitor and reward incompatible
behaviors, and ignore or punish deviant behaviors of the child. This 6 to 8 session approach is
based on Patterson’s coercion theory (1982) and is designed to interrupt the coercive patterns of
interactions that are hypothesized to occur between parents and their conduct-disordered
children. This treatment includes a companion book for parents, Living with Children (1976),
which is often used in conjunction with parent training. Efficacy studies using Patterson’s
treatment approach have included boys and girls between the ages of 6 and 16 years with
conduct-disordered behavior. This treatment has been found to be superior to control groups in
several controlled studies (Alexander & Parsons, 1973; Bernal, Klinnert, & Shultz, 1980;
Firestone, Kelly, & Fike, 1980; Wiltz & Patterson, 1974). Based on the strong empirical support
for Patterson’s approach, a recent review conducted as part of the American Psychological
Association’s (APA) Division 12 Task Force on Effective Psychosocial Interventions judged this
treatment as meeting the stringent criteria for “well-established” psychosocial interventions for
childhood disorders (Brestan & Eyberg, 1998; see Lonigan, Elbert, & Johnson, 1998 for review
of criteria).
R. L. Forehand’s Social Learning Parent Training. Forehand’s Social Learning
Parent Training approach is outlined in his 1981 manual, Helping the Noncompliant Child. This
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10-session treatment approach is based on social learning theory principles and procedures
developed by Constance Hanf at the University of Oregon Health Sciences Center (Hanf, 1968;
Hanf, 1969). The Social Learning Parent Training approach teaches parents to modify
maladaptive parent-child interactions by learning how to attend to positive behavior and
effectively deal with child disruptive behavior. Efficacy studies using Forehand’s treatment
approach have included boys and girls between the ages of 3 and 8 years with noncompliant
behavior. This treatment approach has been found to be superior to control groups in several
controlled studies (Peed, Roberts, & Forehand, 1977; Wells & Eagan, 1988). Based on the
empirical support for Forehand’s approach, the APA Division 12 Task Force on Effective
Psychosocial Interventions judged this treatment as meeting the criteria established for “probably
efficacious” psychosocial interventions for childhood disorders (Brestan & Eyberg, 1998).
R. A. Barkley’s Defiant Children. Barkley’s treatment approach is also based on social
learning theory principles and procedures developed by Hanf (Hanf, 1968; Hanf, 1969). This
program provides behavior management training to parents of children with noncompliance and
attentional problems. Although Barkley (1997) describes this treatment as being optimal for
children with oppositional behavior and attention deficit hyperactivity disorder (ADHD)
between the ages of 2-12 years and numerous studies are cited for the treatment components
included in Defiant Children, no empirical studies have addressed the efficacy of this particular
treatment protocol for the 2 to 12 age group. One empirical study comparing Barkley’s
approach to problem solving/communication training and structural family therapy has provided
evidence for the efficacy of this treatment for adolescents with ADHD between the ages of 12-17
years (Barkely, Guevremont, Anastopoulous, & Fletcher, 1992). Barkley’s use of a token
economy makes this treatment well suited for children with ADHD who respond well to regular
and predictable reinforcement (Newby et al., 1991).
A. E. Kazdin’s “Parent Management Training (PMT)” and “Cognitive-Behavioral
Problem-Solving Skills Training (PSST). Kazdin’s Parent Management Training (PMT)
approach is a manual-based treatment for parents of children with disruptive behavior disorders
(Kazdin, Siegel, & Bass, 1992). PMT is based on a conceptual model that accounts for the
parenting practices and parental cognitive processes that serve to reinforce and maintain
disruptive behavior disorders among children. This 16-session treatment approach was
originally based on Patterson’s Living with Children program, but was broadened to include
cognitive correlates to child antisocial behavior. Kazdin’s Cognitive-Behavioral ProblemSolving Skills Training (PSST) approach is a manual-based treatment for children with
antisocial behavior targeting the cognitive processes that mediate the child’s maladaptive
interpersonal behavior. Treatment outcome research has found that although PMT alone
decreased child antisocial behavior problems, PMT combined with PSST was more effective at
the follow-up assessment (Kazdin, Siegel, & Bass, 1992). The combined PMT and PSST
treatment was also superior to a contact-control group (Kazdin, Esveldt-Dawson, French, &
Unis, 1987). Efficacy studies for Kazdin’s PMT and PSST have included both outpatient and
inpatient children between the ages of 7 and 13 years meeting the DSM-III-R criteria for ADHD,
Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), or Adjustment Disorder (Kazdin,
Esveldt-Dawson, French, & Unis, 1987; Kazdin, Siegel, & Bass, 1992). Although PMT may be
an effective treatment in its own right, the APA Division 12 Task Force on Effective
Psychosocial Interventions judged the combined PMT and PSST treatment to meet the criteria
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established for “probably efficacious” psychosocial interventions for childhood disorders
(Brestan & Eyberg, 1998).
Treatment Components:
Living with Children components
•
Sessions typically conducted without the child.
•
Instruction on social learning theory and coercive theory.
•
Instruction on how to monitor and record the child’s behavior.
•
Use of point system to promote appropriate behavior.
•
Use of positive social reinforcement.
•
Instruction on how to make effective requests.
•
Use of punishment (time out, selective ignoring, overcorrection).
•
Booster sessions.
“Social Learning Parent Training” components
•
Sessions typically conducted with both parent and child.
•
Instruction on social learning theory, the “negative reinforcement trap,” and the “positive
reinforcement trap.”
•
Includes shaping parent’s expectations for child compliance .
•
Instruction on how to use contingent social reinforcement with the child.
•
Modeling, role play, and direct communication with parent while he/she interacts with
the child in the clinic setting.
•
Daily practice of techniques (“Child’s game,” “Parent’s game”), homework assignments.
•
Instruction on how to give effective commands.
•
Use of punishment (time out).
•
Coded home and clinic observations.
“Defiant Children” components:
•
Easily conducted in a group format.
•
Sessions typically conducted without the child.
•
Instruction on social learning theory and the causes of child misbehavior.
•
Instruction on how to use social reinforcement and use shaping to increase positive
behavior.
•
Instruction on how to use incentive programs (behavior charts, token economy).
•
Daily practice of techniques (special nondirective playtime procedure, compliance
training), homework assignments.
•
Instruction on how to give effective commands.
•
Use of punishment (time out).
Kazdin’s Parent Management Training (PMT) components
•
Sessions typically conducted without the child.
•
Sessions include didactic instruction, modeling, role play, and audiotapes of problematic
parent-child interactions.
•
Instruction on how to observe and define behavior.
•
Instruction on how to use positive reinforcement to shape child’s behavior.
•
Instruction on how to negotiate and use behavioral contracts.
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•
•
•
•
Use of punishment (time out) and reprimands.
Use of special contingencies for low-rate behavior.
School consultation.
Use of reinforcers contingent on school behavior.
Kazdin’s Cognitive-Behavioral Problem-Solving Skills Training (PSST) components
•
Sessions are conducted with the child individually.
•
Focuses on problem solving and perspective taking skills.
•
Utilizes practice, modeling, role-play, corrective feedback, and social reinforcement.
•
Utilizes a token economy in session.
•
Homework assignments.
Duration of Treatment:
12-16 weeks
Treatment Manuals or Protocol Descriptions:
Barkley, R. A. (1997). Defiant children: A clinician’s manual for assessment and parent
training. Guilford Press: New York.
Forehand, R. L., & McMahon, R. J. (1981). Helping the noncompliant child: A
clinician’s guide to parent training. Guilford Press: New York.
Patterson, G. R. (1976). Living with children: New methods for parents and teachers.
Champaign, IL: Research Press.
Patterson, G. R., & Gullion, M. E. (1968). Living with children: New methods for parents
and teachers. Champaign, IL: Research Press.
Treatment Outcome Study References:
Alexander, J. F., & Parsons, B. V. (1973). Short-term behavioral intervention with
delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology,
81, 219-225.
Barkley, R. A., Guevremont, A. D., Anastopoulos, A. D., & Fletcher, K. E. (1992). A
comparison of three family programs for treating family conflicts in adolescents with AttentionDeficit Hyperactivity Disorder. Journal of Consulting and Clinical Psychology, 60, 450-462.
Bernal, M. E., Klinnert, M. D., & Schultz, L. A. (1980). Outcome evaluation of
behavioral parent training and client centered parent counseling for children with conduct
problems. Journal of Applied Behavior Analysis, 13, 677-691.
Firestone, P., Kelly, M. J., & Fike, S. (1980). Are fathers necessary in parent training
groups? Journal of Clinical Child Psychology, 9, 44-47.
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Hughes, R. C., & Wilson, P. H. (1989). Behavioral parent training: Contingency
management versus communication skills training with or without the participation of the child.
Child & Family Behavior Therapy, 10, 11-23.
Kazdin, A. E., Esveldt-Dawson, K., French, N. H., & Unis, A. S. (1987). Effects of
parent management training and problem-solving skills training combined in the treatment of
antisocial child behavior. Journal of the American Academy of Child and Adolescent Psychiatry,
26, 416-424.
Kazdin, A. E., Siegel, T. C., & Bass, D. (1992). Cognitive problem solving skills training
and parent management training in the treatment of antisocial behavior in children. Journal of
Consulting and Clinical Psychology, 60, 733-747.
Peed, S., Roberts, M., & Forehand, R. (1977). Evaluation of the effectiveness of a
standardized parent training program in altering the interaction of mothers and their
noncompliant children. Behavior Modification, 1, 323-350.
Wells, K. C., & Egan, J. (1988). Social learning and systems family therapy for
childhood oppositional disorder: Comparative treatment outcome. Comprehensive Psychiatry,
29, 138-146.
Wiltz, N. A., & Patterson, G. R. (1974). An evaluation of parent training procedures
designed to alter inappropriate aggressive behavior of boys. Behavior Therapy, 5, 215-221.
Classification Rating:
3
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Corrective Attachment Therapy
Prepared by Forrest Lien, LCSW, ACSW
Brief Description:
Corrective Attachment Therapy (the Evergreen Model) is a unique synthesis of many
different techniques which are employed to facilitate the development of attachment between
child and parent. These are rooted in an understanding of neurobiological factors, the function
of memory, the effects of trauma, grief and loss, and the critical importance of attachment to the
healthy development of a child. Treatment occurs within the context of a safe, nurturing, and
respectful environment.
Theory and Rationale:
This treatment is based on the premise that children who have not developed an
attachment to a primary caregiver during the first 2-3 years of life are arrested in their
development, as indicated by lack of trust, inability to give and receive genuine affection, lack of
reciprocity in relationships, lack of cause and effect thinking, lack of remorse after hurting
others, as well as manipulative, aggressive and destructive behavior. The treatment presupposes
that these children do not benefit from traditional talk or play therapy that relies on mutual trust,
internal conflict, and emotional honesty and that they have their greatest difficulty in family
settings, where respect and reciprocal interactions are expected. Finally, there is the belief that
these children, left untreated, become over-represented in the prison and criminal justice
population, domestic violence situations, homeless and mental health populations.
Treatment Components:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Contracting
Cognitive restructuring
Role modeling
Behavioral shaping
EMDR
Emotional cathartic therapy
Psycho-educational therapy
Affect regulation (helping a child learn to go in and out of intense emotions and gaining
the ability to regulate and to handle these emotions)
Holding therapy (using a cradling hold such as you would hold and nurture an infant)
Parent/child bonding techniques
Psycho-drama
Guided imagery
Structural family therapy
Sibling therapy
Couples therapy
Existential psychotherapy
Legacy recognition and restructuring (re-decision therapy)
Gestalt therapy
Journaling
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•
•
•
•
•
•
•
•
•
•
Paradoxical techniques
Taking a moral inventory
Making amends
Life scripting
Medication therapy
Motivational therapy (body training)
Sex offender treatment
Therapeutic foster care environment (milieu therapy)
Parent training
Therapist training
Duration of Treatment:
unspecified
Treatment Manuals or Protocol Descriptions:
ATTACh (Association for Treatment and Training in the Attachment of Children).
(undated). Standards of Practice. (See www.attachmentcenter.org for information).
Treatment Outcome Research Studies:
None
Classification Rating:
6
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Family Focused, Child Centered Treatment
Interventions in Child Maltreatment
Prepared by M. Elizabeth Ralston, Ph.D. and Polly B. Sosnowski, MSW
Brief Description:
Focused Treatment Interventions (FTI) is a protocol of sequential treatment interventions
focused on increasing child safety, reducing risk and clarifying responsibility in child
maltreatment cases. FTI is designed for use in a coordinated multidisciplinary community
system of care. The goals of FTI are to identify and reduce barriers to child safety and
protection following the disclosure or discovery of maltreatment and to prevent future abuse.
The sequential nature of the interventions is based on Finkelhor’s (1984) pre-conditions of
motivation, internal, external and child factors as applied to a protective family system.
Theory and Rational:
FTI is based on guiding principles from the empirical literature on the impact of child
maltreatment, child protection state and federal mandates and supports the overarching goal of
family reunification with preconditions of child safety and personal responsibility for behavior.
A uniform and comprehensive forensic and clinical assessment in response to suspected
maltreatment involving the non-offending caregiver and child victim provides a baseline of
history and experience of the child and family. The assessment process is based on the
underlying philosophy that parents and adults are responsible for child protection; the empirical
literature regarding techniques for forensic interviewing; and the American Professional Society
on the Abuse of Children guidelines for conducting psychosocial assessments and forensic
interviews in cases of child maltreatment (American Professional Society on the Abuse of
Children, 1997).
The guiding principles of FTI support beliefs that the safety of the child is paramount;
that family strengthening and reunification are the desired outcomes of community interventions;
the safety of the child is a precondition to family reunification; adults are accountable for any
abusive and /or neglectful behaviors toward their children; acknowledgment of responsibility for
protection and safety is required from the adult caregivers; family strengths and resources in
support of safety and protection are the primary focus of interventions; barriers to future safety
and protection must be identified and overcome in support of family reunification; necessary
community resources are key to supporting the family in overcoming any identified barriers to
safety and protection of the child; contact between child victims and adults who have not been
treated and who do not acknowledge responsibility for their abusive or neglectful or
nonprotective behavior is not in the child’s best interest; a uniform assessment that focuses on
identification of family strengths, risk factors for child safety, and the impact of abuse or neglect
guides the focused interventions in support of family reunification; the overarching goal of
focused interventions is reducing child safety risk and rapid, safe preservation of the child with
family members or safe rapid reunification of the child with a protective caregiver; and when the
goal of family reunification is not possible, early permanency planning is in the best interest of
the child.
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This model focuses on specific factors that created risk to the child and family and
identifies the required behavioral outcome to reduce that risk. Rather than providing a menu of
services that require participation to be considered successful, the FTI focuses on identifying risk
factors and required behavioral change, and uses input from the caregiver regarding what will be
needed to make the required change. For example, when alcohol use is identified as a barrier to
child safety/protection, the FTI directs a specific change in alcohol use behavior. The caregiver
is involved in what will be required to stop using alcohol in support of the safety and protection
of their child. Not using alcohol or not being incapacitated by alcohol is the observable behavior
for success vs. participation in an evaluation or alcohol program for a given length of time. If
the caregiver does not acknowledge alcohol use as a problem or exhibits no motivation to stop
using alcohol, the focused intervention would be on overcoming barriers to motivation vs. forced
participation. This system of interventions focuses the responsibility for change on the caregiver
(client) and places the responsibility for providing the resources to support that change on the
system. This clarifies roles and responsibilities between the “community system” and the family
system and is consistent with the most recent federal mandate and provides documentation
regarding reasonable effort.
Treatment Components:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Comprehensive Assessment
Forensic Medical Exam
Child Safety and Risk Assessment
The Focused Intervention Decision Tree
Protection Clarification
Abuse Clarification
Overcoming Internal Barriers
Overcoming External Barriers
Reducing child factors that have contributed to placing the child at risk
Family Meeting
Identify family and community resources for support regarding child safety/protection
Develop new safety rules, boundaries, roles, and responsibilities between non-offending
caregiver and children within the family and offending caregiver and children within the
family
Monitor family adherence to new rules, alignment of roles, responsibilities
Community Case Review Staffing
Individual treatment
Offender treatment group
Non-offending caregiver support group
Victim support group
Couple treatment
Protection Clarification
Abuse Clarification
Structured family visitation
Family Therapy
Duration of Treatment:
6 to 12 months, dependent upon response of clients
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Treatment Manuals and Protocol Descriptions:
Ralston, M.E. (1998). A community system of care for abused children and their
families. Family Futures, 2(4), 11-15.
Ralston, M.E. (1982). Intrafamilial Sexual Abuse: A community system response to a
family system problem. Charleston, SC: Author.
Ralston, M.E., & Swenson, C.C. (1996). The Charleston Collaborative Project:
Intervention Manual. Charleston, SC: Author.
Lipovsky, J., Swenson, C.C., Ralston, M.E., & Saunders, B.E. (1998). The abuse
clarification process in the treatment of intrafamilial child abuse. Child Abuse & Neglect, 22(7),
729-741.
Treatment Outcome Study References:
Swenson, C.C., & Ralston, M.E. (1997). The Charleston Collaborative Project,
Implementation Manual. Charleston, SC, Author.
Classification Rating:
3
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Family Resolution Therapy (FRT)
Prepared by Benjamin E. Saunders, Ph.D. and Mary B. Meinig, MSW
Brief Description:
Family Resolution Therapy (FRT) is a protocol of procedures designed to help families
where sexual or physical abuse has occurred to develop a long-term resolution for family
relationships. It is concerned with the latter stages of the treatment process with abusing
families and deals with constructing safe, functional, and stable family structures and processes
that will continue well after professional intervention with the family is completed. Resolution
outcomes may range from full family reunification to termination of all parent-child contact.
FRT seeks to maintain an appropriate level of safety for children while enabling children to
maintain the benefits of continuing parent-child relationships where possible.
Theory and Rationale:
FRT is based upon several assumptions drawn from the principles of family systems
theory-based family therapy, family and child development, social learning theory, and theories
of relapse prevention. First, FRT assumes that the growth and development of children is best
promoted when they live in a safe, functional, supportive, and stable family environment,
preferably with their parents. Second, most children develop a lifelong psychological bond or
attachment to their parents that remains even if their parents are abusive, separated from the
child, or incarcerated. Third, many abused children want to continue a relationship with their
parents, though they want the abuse to end and its effects remedied. The FRT protocol assumes
that the child victim, offending parent, and nonoffending parent have been in appropriate victim,
offender, and nonoffending parent therapy programs, and have progressed successfully in those
therapies. FRT outcomes (no contact, minimal contact, significant contact, or reunification) will
depend upon the level of emotional connection children feel for abusive parents, their desire to
maintain their family relationships in some form, and the response of the family to treatment.
The Family Resolution Therapy protocol seeks to develop a long term familial context
and functional processes where children can be safe from abuse, yet continue to benefit from
some type of relationship with their abusive parents. This long term familial outcome may range
from family reunification and maintenance of an intact family, to family separation with
unsupervised visitation, to family separation with supervised visitation, to a complete ending of
the parent-child relationship. FRT employs psychoeducation and cognitive therapy procedures
to change distorted thinking among and between all family members about the abuse experiences
and beliefs that supported the abusive context. It employs family therapy techniques to alter the
homeostatic organizational functioning, internal boundaries, and external boundaries (i.e., social
isolation) of the family system that tended to support and enable the abuse. It employs
behavioral management and collateral monitoring techniques to assess, change, and monitor
behavior among all family members (particularly the offending parent) and the family system as
a whole that may signal a relapse to problem behavior patterns, abusive behaviors, and abuse
supportive behaviors. FRT attempts to change familial behavior by altering the familial
structure and power hierarchy, changing daily family processes, introducing new ways of
conducting familial relationships, and carefully monitoring how new behaviors are implemented
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in the family. It makes use of behavioral contracts and collateral surveillance of family
functioning and individual behavior, as well as psychotherapeutic modalities.
Treatment Components:
•
•
•
•
•
•
•
•
•
•
•
•
•
Monitoring progress of all family members in their individual or group treatment
programs. Insure that victim and offender are in appropriate treatment.
Work closely with victim and offender therapists to assess progress and readiness to
proceed with FRT.
Dyadic therapy with the nonoffending parent and child victim to improve support and
trust
Family therapy with nonoffending parent and sibling group to build familial structural
and process change apart from the offending parent.
Clarification process.
Implementing criteria for initiating therapeutic contacts between the victim and offender.
Teach and implement Family Contact Rules.
Teach and implement Behavioral Alert List..
Implement a Chaperone or Collateral Behavioral Monitoring Program.
Structured family visitation program.
Pre-resolution family therapy
Implement resolution decision-making process.
Post-resolution family therapy.
Duration of Treatment:
6 to 18 months
Treatment Manuals and Protocol Descriptions:
Saunders, B. E., & Meinig, M. B. (2000). Immediate issues affecting long term family
resolution in cases of parent-child sexual abuse. In R.M. Reece (Ed.). Treatment of Child
Abuse: Common Ground for Mental Health, Medical, and Legal Practitioners. Baltimore: The
Johns Hopkins University Press.
Saunders, B.E., & Meinig, M.B. (2001). Family Resolution Therapy in Cases of Child
Abuse. Charleston, SC: Authors
Lipovsky, J., Swenson, C.C., Ralston, M.E., & Saunders, B. E. (1998). The abuse
clarification process in the treatment of intrafamilial child abuse. Child Abuse & Neglect, 22(7),
729-741.
Treatment Outcome Study References:
None
Classification Rating:
4
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Integrative Developmental Model for
Treatment of Dissociative Symptomatology
Prepared by Joyanna Silberg, Ph. D.
Brief Description:
This is a multi-faceted child and family intervention model for children with dissociative
symptoms that emphasizes interrupting automatic dissociative withdrawal, teaching the child
alternative communication strategies and affect management techniques, and helping the family
learn new interactive patterns.
Theory and Rationale:
Some children with trauma histories may present with symptoms such as trance states,
forgetfulness, fluctuating behavior including rapid regressions and rage reactions, and belief in
vivid imaginary friends or divided identities (Silberg, 2000). Traumatic events in the child's life
may precipitate these adaptations as ways to cope with a dysfunctional environment. These
adaptations may be understood as difficulties in the normal developmental integration of
self-capacities (Siegel, 1999; Putnam, 1997). Treatment involves emphasis on self-awareness
and affect regulation and encouraging the child to take responsibility for actions that the child
may initially perceive as outside of his/her control. Interactions with the child emphasize
acceptance of all affects, behaviors or dissociated states and the encouragement of
self-acceptance as a first step towards self-management. Development of positive fantasy for
providing self-soothing illustrates to the child that fantasy, such as belief in malevolent
imaginary entities, can be under the child's control. Treatment must keep in mind normal
developmental expectations and avoid iatrogenic influences that support the child or family's
belief in the literal reality of dissociated identities. Recent research suggests that children with
disorganized or avoidant attachment styles may be particularly at risk for developing dissociative
symptomatology (Ogawa et al, 1997). Thus, enhancing parent child attachment patterns and
communication becomes important. Treatment emphasizes the identification of stimuli that may
elicit dissociative responses such as parent-child interaction patterns that are reminiscent of
previous traumatic episodes, in which attachment was threatened. Family interventions involve
enhancing reciprocity in communication, encouraging direct expression of feeling (Wieland,
1998) and avoiding the reinforcement of regressive coping (Silberg, 2001). The therapist models
for the child and family interactive styles that encourage wholeness, responsibility, and tolerance
for the expression of feelings.
Treatment Components:
Child
•
Identify precursors for transitions in state and learn to self-regulate state transitions.
•
Learn direct communication of feelings and self-regulation .
•
Promote self-awareness, and self-acceptance of all feelings , behaviors and sensations
leading to increased responsibility.
•
Highlight differences between "then" and "now" emphasizing current safety in the
environment.
•
Use imagery, play, or art to self-soothe and provide mastery over traumatic experiences.
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Family
•
Consistently hold the child responsible for behavior even if perceived as outside of
child's control.
•
Encourage families to allow expression of affect and acceptance of the whole child.
•
Enhance communication encouraging speaking about the trauma and the family's,
(previous family's, society's) inability to keep the child safe.
•
Avoid reinforcement of regressive coping, or literal view of the child's perception of
divided self.
Duration of Treatment:
6 to 24 months
Treatment Manuals or Protocol Descriptions:
International Society for the Study of Dissociation. (2000). Guidelines for the evaluation
and treatment of dissociative symptoms in children and adolescents. Journal of Trauma and
Dissociation, 1(3), 105-154.
Ogawa, J. R., Sroufe, L. A., Weinfield, N. S., Carlson, E. A., & Egeland, B. (1997).
Development and the fragmented self: Longitudinal study of dissociative symptomatology in a
nonclinical sample. Development and Psychopathology, 9, 855-879.
Putnam. F. W. (1997). Dissociation in children and adolescents. New York: Guilford
Silberg, J. L. (2001). Treating maladaptive dissociation in a young teen-age girl, in H.
Orvaschel, J. Faust, & M. Hersen (Eds.), Handbook of conceptualization and treatment of child
psychopathology. New York: Pergamon Press.
Silberg, J L.(2000). Fifteen Years of Dissociation in Maltreated Children: Where do we
go from here? Child Maltreatment, 5, 2, 119-136.
Wieland, S. (1998). Techniques and Issues in abuse-focused therapy. Thousand Oaks,
CA: Sage Publications.
Treatment Outcome Study References:
None
Classification Rating:
4
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Intensive Family Preservation Services
Prepared by Charlotte Booth, MSW
Brief Description:
This protocol is a brief, home-based multiple component intervention designed to prevent
child out of home placement and reduce risk for child maltreatment by changing behaviors and
increasing skills. Treatment components are primarily cognitive-behavioral and matched to
identified problem areas.
Theory and Rationale
Families where there has been child abuse or are at high risk often experience problems
in functioning that can lead to child placement. Parental skill deficits and psychiatric conditions,
child behavior problems, and dysfunctional or violent family relationships contribute to the
possibility of family disruption. The HOMEBUILDERS program and similar programs use a
cognitive behavioral framework to explain the variety of behavioral dysfunctions. The
intervention approach consists of the individualized in-home application of a variety of cognitive
behavioral and skill-building strategies that target the specific problems that are identified in the
family and that create imminent risk of out-of-home placement. The specific strategies used
have extensive empirical support (Ammerman, et. al., 1999; Patterson, et. al., 1982; Wahler and
Dumas, 1987; Alexander and Parsons, 1973, 1982; Gorman, Kniskern, & Pinsof, 1986). The
program approach has also been used for family reunification following foster care (Fraser,
Walton, Lewis, Pecora, & Walton, 1996).
A substantial amount of research has been conducted on IFPS programs including several
large randomized trials. Although a large majority of treated cases avoid placement, most
studies do not find a statistically significant difference in placement rates, suggesting that many
of the families referred for the service were not actually at imminent risk for placement (Fraser,
Nelson, & Rivard, 1997). Use of IFPS appears to accelerate family reunification (Fraser, et al,
1996). Overall rates of subsequent child maltreatment tend to be low in treated and untreated
groups, and groups usually do not differ following intervention. However, lower rates of
subsequent child maltreatment have been found in at least one subgroup (Westat, Inc., Chapin
Hall Center for Children, & James Bell Associates, 2001). Results of a recent large scale
randomized trial in three states showed that where differences were found on family functioning
and child problems, the majority favored the IFPS intervention.
Treatment Components:
•
•
•
•
•
•
•
•
Service provision in the client home
Engagement and relationship building through Rogerian listening techniques
Behavioral assessment of client strengths and needs
Goal-oriented service planning
Cognitive-behavioral parenting and problem solving techniques
Life-skills training
Provision of concrete services (e.g., assistance with housing)
Building client social support networks
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•
Motivational Interviewing and relapse prevention strategies for parents with substance
abuse problems
Treatment Manuals or Protocol Descriptions:
Kinney, J.M., Haapala, D., and Booth, C.L. (1991). Keeping Families Together: The
Homebuilders Model. New York: Aldine de Gruyter.
Tracy, E.M., Haapala, D.A., Kinney, J., and Pecora, P.J. (Eds.) (1991). Intensive Family
Preservation Services: An Instructional Sourcebook. Cleveland, OH: Mandel School of Applied
Social Sciences, Case Western Reserve University.
Whittaker, J.K., Kinney, J.M., Tracy, E.M. Booth, C.L. (Eds.) (1990). Reaching high-risk
families: Intensive family preservation in human services. New York: Aldine de Gruyter.
Duration of Treatment:
3 to 6 months
Treatment Outcome Study References:
Fraser, M.W., Walton, E., Lewis, R.E., Pecora, P., & Walton, W. (1996). An experiment
in family reunification: Correlates of outcomes at one-year follow-up. Children and Youth
Services Review, 16, 335-361.
Pecora, P.J., Fraser, M.W., Bennett, R.B., & Haapala, D.A. (1991) Placement rates of
children and families served by intensive family preservation services programs. In M.W. Fraser,
P.J. Pecora, & D.A. Haapala. Families in Crisis: The Impact of Intensive Family Preservation
Services. (pp. 149-180) New York: Aldine de Gruyter.
Schwartz, I.M., AuClaire, P., & Harris, L. (1991). Family preservation services as an
alternative to the out of home placement of adolescents: The Hennepin County experience. In K.
Wells & D.E. Biegel (Eds.) Family preservation services: Research and evaluation. (pp. 33-46).
Newbury Park, CA: Sage.
Westat, Inc., Chapin Hall Center, & James Bell Associates (2001) Evaluation of family
preservation and reunification programs: Interim report. Washington, DC: DHHS
Classification Rating:
4
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Multisystemic Therapy (MST) for Maltreated Children and their Families
Prepared by Cynthia Cupit Swenson, Ph.D. and Scott W. Henggeler, Ph.D.
Brief Description:
Multisystemic Therapy (MST) is a treatment model that targets key factors within the
youth’s social ecology that relate to problem behavior and provides multiple, comprehensive
interventions that have empirical support.
Theory and Rationale:
The theoretical foundation underlying MST is based on causal modeling studies of
serious antisocial behavior (Henggeler, 1991) and social-ecological (Bronfenbrenner, 1979) and
family systems (Haley, 1976; Minuchin, 1974) theories of behavior. Behavior is viewed as
multidetermined and, consequently, problem behavior may be maintained by difficulties within
any of the pertinent systems (e.g., family, peer, school, community) in which the youth is
involved. Thus, the scope of MST interventions is not limited to an individual youth or the
family system, but includes difficulties within and between other systems.
MST was originally developed in the late 1970’s to address youth antisocial behavior and
has been identified as a highly promising treatment model by reviewers in the fields of substance
abuse (e.g., McBride, VanderWaal, Terry, & VanBuren, 1999; National Institute on Drug Abuse,
1999; Stanton & Shadish, 1997), adolescent violence (e.g., Elliott, 1998; Farrington & Welsh,
1999; Tate, Reppucci, & Mulvey, 1995), and mental health (e.g., Kazdin & Weisz, 1998; U.S.
Department of Health and Human Services, 1999). Eight randomized clinical trials have been
published with youth presenting serious clinical problems and their families, and several others
are currently underway. The majority of these trials have been conducted in field settings, and
the targeted populations have included inner-city delinquents (Henggeler et al., 1986), three
trials with violent and chronic juvenile offenders (Borduin et al., 1995; Henggeler et al., 1997;
Henggeler, Melton, & Smith, 1992; Henggeler, Melton, Smith, Schoenwald, & Hanley, 1993),
substance abusing or dependent juvenile offenders with high rates of psychiatric comorbidity
(Brown, Henggeler, Schoenwald, Brondino, & Pickrel, 1999; Henggeler, Pickrel, & Brondino,
1999; Schoenwald, Ward, Henggeler, Pickrel, & Patel, 1996), youths presenting psychiatric
emergencies (i.e., suicidal, homicidal, psychotic) (Henggeler, Rowland et al., 1999; Schoenwald,
Ward, Henggeler, & Rowland, 2000), and juvenile sexual offenders (Borduin, Henggeler,
Blaske, & Stein, 1990). Results from these studies support the short- and long-term clinical
effectiveness of MST as well as its potential to produce significant cost savings and capacity to
retain families in treatment. In comparison with control groups, MST has consistently
demonstrated improved family relations and family functioning, improved school attendance,
decreased adolescent drug use, 25% to 70% decreases in long-term rates of rearrest, and 47% to
64% decreases in long-term rates of days in out-of-home placements.
Given that a large body of literature supports a multidetermined etiology of child
maltreatment, comprehensively addressing the factors that may drive maltreatment seems
logical. To date one randomized trial has taken on this challenge by evaluating the effectiveness
of MST versus parent training with abusive and neglectful families (Brunk, Henggeler, &
Whelan, 1987). MST was more effective than Parent Training for improving parent-child
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interactions associated with maltreatment. Abusive parents showed greater progress in
controlling their child’s behavior, maltreated children exhibited less passive noncompliance, and
neglecting parents became more responsive to their child’s behavior. Parent training was
superior to MST on decreasing social problems (i.e., social support network). Although
outcomes were promising, no follow-up was conducted. MST is currently being tested
specifically with physically abusive families in a randomized trial.
Treatment Components:
•
•
•
•
•
•
•
Assessment to understand the “fit” between the identified problems and their broader
systemic context. For example fit factors that explain maltreatment may include poor
anger management, substance abuse, limited parenting skills.
With the youth, family, and other people in the youth’s ecology, determine overarching
goals of treatment.
Determine systemic strengths and use those as levers for change (e.g., supportive
extended family that can help with child monitoring).
Develop present-focused and action-oriented interventions that have empirical support
and target the fit factors (e.g., cognitive behavioral techniques for anger management are
taught to the abusive parent and spouse who can help with implementation).
Implement interventions in the family home or community and at times that are
convenient for families.
Implement interventions that empower the family; that is, interventions that allow
families to do for themselves rather than having the therapists do for them.
Evaluation of intervention efficacy continuously and from multiple perspectives.
Duration of Treatment:
4 to 6 months
Treatment Manuals or Protocol Descriptions:
Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham,
P. B. (1998). Multisystemic treatment of antisocial behavior in children and adolescents. New
York: Guilford Press.
Treatment Outcome Study References:
Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M.,
& Williams, R. A. (1995). Multisystemic treatment of serious juvenile offenders: Long-term
prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 63, 569578.
Brunk, M., Henggeler, S. W., & Whelan, J. P. (1987). A comparison of multisystemic
therapy and parent training in the brief treatment of child abuse and neglect. Journal of
Consulting and Clinical Psychology, 55, 311-318.
Henggeler, S. W., Pickrel, S. G., & Brondino, M. J. (1999). Multisystemic treatment of
substance abusing and dependent delinquents: Outcomes, treatment fidelity, and transportability.
Mental Health Services Research, 1, 171-184.
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Henggeler, S. W., Rowland, M. R., Randall, J., Ward, D., Pickrel, S. G., Cunningham, P.
B., Miller, S. L., Edwards, J. E., Zealberg, J., Hand, L., & Santos, A. B. (1999). Home-based
multisystemic therapy as an alternative to the hospitalization of youth in psychiatric crisis:
Clinical outcomes. Journal of the American Academy of Child & Adolescent Psychiatry, 38,
1331-1339.
Classification Rating:
3
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Parent-Child Education Program for Physically Abusive Parents
Prepared by David Wolfe, Ph.D.
Brief Description:
This protocol is a home- or clinic-based intervention designed to establish positive
parent-child interactions and childrearing methods that are responsive to situational and
developmental changes and reduce parents’ reliance on power-assertive methods that can turn
into verbal and physical abuse.
Theory and Rationale:
Child physical abuse occurs most often during periods of stressful role transition for
parents, such as the postnatal period of attachment, the early childhood period of increasing
socialization pressures, times of family instability and disruption, or following chronic
detachment from social supports and services (Wolfe, 1999). This approach is derived from
attachment theory, with its emphasis on early relationship formation, and social learning theory’s
principles of behavioral and cognitive learning. Training parents in effective childrearing
methods is based on practical applications of learning principles: educating parents about very
basic contingency management principles (e.g., reinforcement, punishment, consistency, etc.);
modeling for the parents (via films or live demonstrations) new ways of problem-solving and
increasing child compliance; rehearsing the desired skills in non-threatening situations, with
increasingly more and more realistic applications (i.e., practicing in the home with the therapist);
and providing feedback (verbal or videotaped) to the parents regarding their performance
(Becker, Alpert, BigFoot, Bonner, Geddie, Henggeler, Kaufman, & Walker, 1995; Wolfe &
Wekerle, 1993). The goals of intervention involve the development of strong positive
child-rearing abilities by strengthening the early formation of the parent-child relationship,
improvement in the parent's abilities to cope with stress through exposure to a mental health
support system, and the development of the child's adaptive behaviors that will contribute to his
or her emotional and psychological adjustment. These methods emphasize education and
guidance in a format that is flexible and responsive to the needs of families and individuals.
Intervention is often re-directed toward important issues that families face during each of the
emerging developmental stages that the child and parent must endure. For example, parents who
require concrete demonstration of methods to promote child compliance, are socially-isolated, or
demonstrate anger control problems are offered individual or group intervention designed to
teach skills such as nonviolent discipline methods, self-control, and ways to access community
resources.
Treatment Components:
Methods for Enhancing Parental Sensitivity
•
Connecting parents to corollary services in the community that provide peer activities,
social support, and childcare assistance.
•
Having parents watch and follow child's actions, without directing or interfering.
•
Teaching parents to speak loudly and clearly, and provide some narrative aloud of the
child's ongoing activity.
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•
•
•
•
Learning to display positive emotion spontaneously while watching and playing with
their child.
Learning to use verbal praise, hugs, and other positive reactions to the child's appropriate
behavior.
Focusing on any special needs of the child during training exercises with parents.
Teaching child, via parental activities, to extend his/her attention span gradually and
develop appropriate forms of communication and expression of positive emotion.
Setting Reasonable Expectations for Children's Emotional and Behavioral Development
•
Teaching activities to promote child's language and interpersonal skills development.
•
Parental review of their child expectations with therapist, and work at defining and
setting appropriate limits and expectations.
•
Learning to use verbal guidance and proper commands with child, when attempting to
teach child or to limit child's off-task behavior.
•
Learning to use unambiguous, appropriate expressions of affect when giving commands,
monitoring compliance or activities of the child, and when administering praise and
expressing interest.
•
Teaching child to attend to tasks and activities for longer periods of time, and begin to
display an enthusiasm for learning and playing.
•
Teaching child compliance to parental requests, in accordance with their level of
development and (modified) parental expectations.
•
Strengthen child’s developmental weaknesses in communication and social interaction.
Anger Control and Effective Discipline Strategies
•
Learning to handle minor frustrations and setbacks with the child, by using humor,
distraction, meaningful activities, and simple coping statements.
•
Applying basic skills to ongoing problems they have identified with their child.
•
Identifying sources of anger and its self-expression, and learning to control arousal prior
to disciplining child.
•
Understanding the "rules of punishment" and clarifying their expectations for its shortand long-range impact.
•
Using non-physical, behavior-focused alternatives to corporal punishment, verbal
coercion, or emotional abuse.
•
Practice anger control and appropriate discipline while engaging in live, provocative
situations with their child.
•
Teaching child to respond to non-coercive, non-violent discipline methods without
escalating conflict.
Duration of Treatment:
4 to 12 months. Follow-up may occur for 1 to 2 years
Treatment Manuals or Protocol Descriptions:
Wolfe, D. A. (1991). Preventing physical and emotional abuse of children. New York:
Guilford Press.
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Treatment Outcome Study References:
Wolfe, D. A., Sandler, J., & Kaufman, K. (1981). A competency-based parent training
program for child abusers. Journal of Consulting and Clinical Psychology, 49, 633-640.
Wolfe, D. A., St. Lawrence, J., Graves, K., Brehony, K., Bradlyn, A., & Kelly, J. A.
(1982). Intensive behavioral parent training for a child abusive mother. Behavior Therapy, 13,
438-451.
Wolfe, D. A., Edwards, B., Manion, I., & Koverola, C. (1988). Early intervention for
parents at-risk for child abuse and neglect: A preliminary investigation. Journal of Consulting
and Clinical Psychology, 56, 40-47.
Classification Rating:
3
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Parent-Child Interaction Therapy (PCIT)
Prepared by Anthony Urquiza, Ph.D.
Brief Description:
This intervention is a behavioral and interpersonal dyadic intervention for children (ages
2-8 years) and their parents or caregivers that is focused on decreasing externalized child
behavior problems (e.g., defiance, aggression), increasing positive parent behaviors, and
improving the quality of the parent-child relationship.
Theory and Rationale:
There are many underlying factors that contribute to the development of physically
abusive families. Foremost among these factors is the nature of the parent-child relationship.
Abusive parents are characterized by high rates of negative interaction, low rates of positive
interaction, and limited and ineffective parental disciplining strategies (Kolko, 1995). At the
same time, physically abused children have been reported to be aggressive, defiant, noncompliant, and resistant to parental direction (Kolko, 1995). These patterns of interaction result
in a negative and coercive parent-child relationship that may escalate to the point of severe
corporal punishment and physical abuse (Urquiza & McNeil, 1996). This pattern eventually can
become a relatively stable form of resolving parent-child conflicts that also generates ongoing
risk for child maltreatment. While it is likely that there are many different types of physically
abusive parent-child relationships, this particular cycle may explain a substantial portion of
physical abuse situations, especially those that evolve from routine daily interactions around
compliance and discipline. Parent-Child Interaction Training (PCIT) was developed by Sheila
Eyberg to address families with negative interactional patterns where the children are
oppositional and defiant and has been shown to be effective with these high-risk families
(Eyberg, 1988). It is an intervention that is especially appropriate for use in physical abusive
situations because it targets the specific deficits often found within physically abusive parentchild dyads that can lead to maltreatment. The approach incorporates both the parent and the
child (and other involved family members) in the intervention process. It provides an in vivo
opportunity to alter the pattern of interactions within abusive relationships, and it serves as a
mechanism to directly decrease negative affect and control - while promoting greater positive
affect and discipline strategies. The interventions combine elements of family systems, learning
theory and traditional play therapy. The emphasis is on restructuring parent-child patterns, not
modifying behaviors (Hembree-Kigin & McNeil, 1995). The therapist takes an extremely active
and directive role in the process. The intervention consists of an initial set of approximately six
sessions devoted to enhancing positive interactions, and then another six that focus on improving
disciplinary practices. Progress is tracked and once parents achieve competence in one area they
shift the treatment focus.
Treatment Components:
•
Establish a therapeutic alliance and explain treatment process.
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Child Directed Interaction
•
Parent is taught the elements of the acronym PRIDE (P = praise, R = reflect, I =
imitation, D = description, E = enthusiasm).
•
Parent is encouraged not to use “No-Don’t-Stop-Quit-Not” in interactions with child.
•
The parent is instructed to interact/play with the child and to ask the child to clean up for
specified periods of time while being observed from behind a one way mirror.
•
The parent wears a FM-signal audio reception device (commonly referred as a ‘bug-inthe-ear’) to listen to directions, prompts, and instructions.
•
The PCIT therapist is in an adjoining observation room and observes specific behaviors
and interpersonal dynamics, then provides prompts and feedback (i.e., suggestions,
praise, correction) to the parent to promote PRIDE and decrease “No-Don’t-Stop-QuitNot”.
•
Specific behaviors are tracked and charted on a graph at periodic intervals to provide
parents with specific information about progress in positive interactions and the
achievement of mastery.
Parent Directed Interaction
•
Parent is instructed in giving commands and directions.
•
Child is given a difficult task that may evoke disobedience/defiance or other behaviors.
•
Parent receives coaching through the “bug-in the-ear” to help the child practice minding.
•
Parent is instructed in ways to generalize the skills to siblings, and “problem times”.
Duration of Treatment:
6 sessions devoted to relationship enhancement; 6 sessions on disciplinary practices
Treatment Manuals or Protocol Descriptions:
Hembree-Kigin, T., & McNeil, C.B. (1995). Parent-Child Interaction Therapy. New
York: Plenum.
Urquiza, A.J., Zebell, N., McGrath, J., & Vargas, E. (1999). Parent-Child Interaction
Therapy: Application to high-risk and maltreating families. Unpublished treatment manual.
Author. Child Protection Center, Department of Pediatrics, University of California Davis
Medical Center, 3300 Satockton Blvd., Sacremento, CA 95820
Urquiza, A.J., Zebell, N., McGrath, J., & Vargas, E. (1999). Parent-Child Interaction
Therapy: Application to high-risk and maltreating families. Videotape series. Author. Child
Protection Center, Department of Pediatrics, University of California Davis Medical Center,
3300 Satockton Blvd., Sacremento, CA 95820
Urquiza, A.J., & McNeil, C.B. (1996). Parent-child interaction therapy: An intensive
dyadic intervention for physically abusive families. Child Maltreatment, 1(2), 132-141.
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Treatment Outcome Study References:
Borrego, J., & Urquiza, A.J. (1998). Importance of therapist use of social reinforcement
with parents as a model for parent-child relationships: An example with Parent-Child Interaction
Therapy. Child and Family Behavior Therapy, 20(4), 27-54.
Borrego, Jr., J., Urquiza, A.J., Rasmussen, R.A., & Zebell, N. (1999). Parent-Child
Interaction Therapy with a Family at High-Risk for Physical Abuse. Child Maltreatment, 4(4),
331-342.
Eyberg, S.M. (1988). Parent-child interaction therapy: Integration of traditional and
behavioral concerns. Child and Family Behavior Therapy, 10, 33-46.
Eyberg, S., & Robinson, E.A. (1982). Parent-child interaction training: Effects on family
functioning. Journal of Clinical Child Psychology, 11, 130-137.
Classification Rating:
3
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Physical Abuse-informed Family Therapy
Prepared by David Kolko, Ph.D.
Brief Description:
This treatment approach is a family systems intervention for children and physically
abusive parents that seeks to reduce violence and improve child outcomes by promoting
cooperation, developing shared views about the value of non-coercive interactions, and
increasing skills of family members
Theory and Rationale:
The family-ecological model views child physical abuse from a systemic perspective
emphasizing the interrelationships among individual, family, and social support factors (e.g.,
family communication, extra familial contacts; Belsky, 1993). Treatment seeks to address
various child (e.g., feelings), parent (e.g., poor empathy, physical punishment) and/or family
issues (e.g., role reversal). Most interventions involving family therapy (FT) or multiple services
directed toward the family system have not been formally evaluated (see Wolfe & Wekerle,
1993). Family-centered services have been associated with improvements in child developmental
status, parenting skill, and family relationships (Brunk, Henggeler, & Whelan, 1987; Culp,
Little, Letts, & Lawrence, 1991; Nicol, Smith, Kay, Hall, Barlow, & Williams, 1988). However,
such outcomes are qualified by the absence of follow-up data (Brunk et al., 1987), high attrition
(Nichol et al., 1988), and the limited maintenance of treatment effects (Lutzker, 1990). Abuseinformed FT is designed to enhance family functioning and relationships (Alexander & Parsons,
1982; Robin & Foster, 1989), in accord with the interactional or ecological model approach to
child maltreatment (Belsky, 1993). Treatment seeks to enhance the cooperation and motivation
of all family members by promoting an understanding of coercive behavior, teaching the family
positive communication skills and how to solve problems together. The treatment has been
shown to be superior to routine community service in reducing violence and improving child
outcomes (Kolko, 1996c).
Treatment Components:
Engagement phase
•
Assessment of the family's structural roles and interactions (e.g., genogram).
•
Reframing to enhance cooperation among family members (Alexander & Parsons, 1982;
Szapocnik & Kurtines, 1989).
•
Discussion of the negative effects of the use of physical force.
•
Agreement to a no-violence contract by all family members (Anderson & Reiss, 1983).
Skill-building phase
•
Training to use specific problem solving and communication skills at home (Robin &
Foster, 1989).
Application/termination phase
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•
Establishing problem-solving family routines as alternatives to coercion or physical
punishment (Szapocnik & Kurtines, 1989).
Duration of Treatment:
12 to 24 sessions
Treatment Manuals or Protocol Descriptions:
Kolko, D.J., & Swenson, C.C. (2002). Assessing and treating physically abused children
and their families: A cognitive-behavioral approach. Thousand Oaks, CA: Sage Publications.
Swenson, C.C. & Kolko, D.J. (2000). Long-term management of the developmental
consequences of child physical abuse. In R. Reece (ed.). The treatment of child abuse.
Baltimore, MD: Johns Hopkins University Press.
Treatment Outcome Study References:
Kolko, D.J. (1996) Individual cognitive behavioral therapy and family therapy for
physically abused children and their offending parents: A comparison of clinical outcomes.
Child Maltreatment, 1, 322-342.
Classification Rating:
3
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Parents United
(Child Sexual Abuse Treatment Program)
Prepared by Debra A. Johnson, Ph.D.
Brief Description:
Parents United is a clinically based, integrated treatment program which provides direct
clinical services as well as a variety of non-clinical support for victims, offenders, adults
molested as children, and their support persons. The clinical services are provided by the clinical
sponsoring agency for the Parents United chapter and the non-clinical support services are
provided by the Parents United membership itself.
Theory and Rationale:
Parents United is based on the idea that all individuals affected by sexual abuse will
benefit from a variety of supportive, adjunctive services in addition to formal clinical
interventions. The services include immediate access to information and a supportive response
from others who have had similar experiences, as well as concrete assistance with some of the
impacts following discovery of abuse. Groups targeted for various sub-populations, including
adults molested as children, offenders, denying offenders, offenders who are also victims,
parents of abused children and teenage child victims and their offenders, provide a place of
mutual recovery, allow participants to address and listen to each other, and serve as a vehicle for
developing insight, empathy and understanding. Support persons are also included to enhance
the available support system for the involved individuals. Variations on psychoeducation,
support, enhancement of interpersonal skills, and cognitive behavioral techniques are used.
Some of the groups are progressive; clients move from one to the other as they achieve certain
goals. Others are specific to a particular purpose. Most groups meet once a week for eight
weeks. In addition, Parents United serves the community at large through a speaker’s bureau.
Participants create awareness and understanding through sharing their experiences.
Parents United is a nonprofit, membership driven organization which provides most
nonclinical support functions for the program. These functions include child care, attendance
records, speakers bureaus, support person registry, literature on the program, orientation of
membership, etc. Each Parents United Chapter has a clinical sponsoring agency responsible for
all treatment services. In the Stanislaus County, California chapter, this agency is Child Sexual
Abuse Treatment Services, a for profit agency. This agency provides licensed or license-eligible
clinicians and psychologists to lead groups. The theoretical orientation of this program is largely
cognitive-behavioral, with relapse prevention being the predominant methodology for offender
treatment.
Treatment Components:
Non-clinical Supports
•
Information/referral line
•
Member Support Services
•
Child care
•
Supervised child visitation
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•
Speakers bureau
Clinical Supports
•
Program Orientation Group (adults molested as children, offenders, parents of victims,
support persons).
•
Newcomers Group (adults molested as children, offenders, parents of victims, support
persons).
•
Psychoeducation about abuse impact on victims/need for support.
•
Confrontation/accountability.
•
Explanation of treatment process/expectations .
Adults Molested as Children Groups
•
To relieve the adult of all feelings of responsibility for childhood victimization
•
To empower change and emphasize that each individual has the power to
effectively
change and successfully manage his/her life
•
To expand behavioral options which enable a self fulfilling lifestyle and relationships
•
Learn to trust again
•
Deal and resolve all feelings associated with the trauma
•
Establish self-affirming relationship with non-offending family members
Offender Groups
•
Eliminate denial
•
Increase personal responsibility-taking for offenders
•
Expose/address cognitive behavioral deficits/dysfunctions that precipitate offending
•
Increase self-management skills
•
Identify the self-destructive impact of abusing
•
Label/articulate feelings, cognition, behaviors
•
Identify needs in relationship/learn difference between intimacy and manipulation,
control and sexualization in relationships
•
Learn skills for building healthy adult relationships
•
Develop a personal risk assessment/prevention plan to reduce risk of future offending
•
Identify/acknowledge childhood abuse experiences
Victim/Offender Group (offenders who are also victims)
•
Discuss childhood abuse experience
•
Assign full responsibility to offender
•
Label/express abuse-related feelings
•
Identify how abuse-related feelings interfere with achieving current goals
•
Re-evaluate/restructure personal relationships
•
Increase self management skills
Recontact Group (offenders, adults molested as children, support persons)
•
Acknowledge, label, and articulate personal feelings, cognition and behaviors
•
Identify what is missing and what is wanted in trust/interpersonal relationships
•
Acknowledge the difference between intimacy and the manipulation, control, and
sexualization of others
•
Accept responsibility for building appropriate adult relationships
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•
•
•
•
•
•
•
•
•
Learn the skills required to build appropriate adult relationships
Practice empathy and social awareness when interacting with others
Verbalize, increase understanding and value of the self and others
Develop a personal risk assessment/prevention plan that establishes when, how, and
where to access help to decrease the risk of future molests
Stress management
Active listening
Acceptance of intra-personal change
Empathic, intimate relationship skills
Goal planning
Parent Group (parents of child victims)
•
Information/help with access to resources
•
Ventilate feelings about abuse
•
Discuss the child=s abuse experience
•
Psychoeducation about abuse dynamics/impact
•
Improve parenting skills
Shared Perceptions Group (adults molested as children, child victims > 12 years, offenders,
parents, and support persons)
•
Tot’s Group (ages 2 through 5)
•
Resolve feelings about abuse
•
Learn appropriate assertive skills
Children’s Group I (ages 6 through 8)
•
Resolve feelings about abuse
•
Learn appropriate assertive skills
Children’s Group II (ages 9 through 12)
•
Resolve feelings about abuse
•
Learn appropriate assertive skills
Violation of Rights Group
•
Eliminate denial
•
Increase personal responsibility-taking for offenders
•
Expose/address cognitive behavioral deficits/dysfunctions that precipitate offending
•
Increase self-management skills
•
Identify the self-destructive impact of abusing
•
Label/articulate feelings, cognition, behaviors
•
Identify needs in relationship/learn difference between intimacy and manipulation,
control and sexualization in relationships
•
Learn skills for building healthy adult relationships
•
Develop a personal risk assessment/prevention plan to reduce risk of future offending
•
Identify/acknowledge childhood abuse experiences
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Teen Offenders Group
•
Eliminate denial
•
Increase personal responsibility-taking for offenders
•
Expose/address cognitive behavioral deficits/dysfunctions that precipitate offending
•
Increase self-management skills
•
Identify the self-destructive impact of abusing
•
Label/articulate feelings, cognition, behaviors
•
Identify needs in relationship/learn difference between intimacy and manipulation,
control and sexualization in relationships
•
Learn skills for building healthy adult relationships
•
Develop a personal risk assessment/prevention plan to reduce risk of future offending
•
Identify/acknowledge childhood abuse experiences
Teen Male Victim Group
•
Resolve feelings about molest
•
Learn appropriate assertive skills
•
Learn skills for building healthy relationships
High School Girls Group
•
Resolve feelings about molest
•
Learn appropriate assertive skills
•
Learn skills for building healthy relationships
Junior High School Girls Group
•
Resolve feelings about molest
•
Learn appropriate assertive skills
•
Learn skills for building healthy relationships
Duration of Treatment:
typically 8 weeks for each group, open-ended for total program
Treatment Manuals or Protocol Descriptions:
Child Sexual Abuse Treatment Services. (1994). Treatment Manual for Child Sexual
Abuse Treatment Services. Modesto, CA: Author.
Giarretto, H., & Einfeld-Giarretto, A. (undated). Integrated Treatment: The Self-Help
Factor- L-10. Giarretto Institute, Training Department- Literature Order, 232 East Gish Road,
San Jose, California 95112.
Treatment Outcome Study References:
Abbott, B. (undated). Sexual Re-offense Rate Among Incest Offenders 8 Years After
Leaving Treatment- L-15. Giarretto Institute, Training Department- Literature Order, 232 East
Gish Road, San Jose, California 95112.
Classification Rating:
4
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Parents Anonymous®
Prepared by Rochelle F. Hanson, Ph.D. and Sheri Rosen
Brief Description:
Parents Anonymous, Inc. is an organization designed to strengthen at-risk and abusive
parents or adults in parenting roles through mutual support, shared leadership and personal
growth. The ongoing, open-ended groups offer the opportunity to learn new skills, transform
attitudes and behaviors, and create lasting change.
Theory and Rationale
Parents Anonymous® is based on the idea that through participation in groups parents
learn to identify and build on their strengths, increase their ability to deal with stress, expand
their social support networks, and develop realistic expectations of themselves and their
children. Parents are encouraged to take responsibility for their own problems and give and get
support from one another to find solutions. Parents Anonymous® groups provide support, a safe
and caring environment, encouragement to parents for taking charge of their lives and their
families, and opportunities for attitude change and the integration of new knowledge and skills.
Providing opportunities to develop friendships reduces isolation. The three essential
components needed to create long-term behavioral change are the opportunity to: (1) examine
attitudes and childrearing practices and learn new skills and behaviors, (2) practice newly
learned skills and behaviors within the safety of the group and at home, and (3) incorporate the
new skill or behavior into their daily life.
Parents Anonymous® encourages parents to ask for help early, whatever their
circumstances, in order to effectively break the cycle of abuse and strengthen their families.
Weekly, Parents Anonymous® groups are co-led by parents and professionally trained facilitators
and are free of charge to participants. Parents or adults in parenting roles (e.g., grandparents,
aunts, uncles, foster parents, stepparents, or older siblings) who are concerned about their
parenting abilities and seeking support, information and training are welcome at Parents
Anonymous® groups, whatever the age of their children or their current circumstances. Parents
Anonymous® groups are ongoing and open ended; parents can join at any time and participate as
long as they wish. Group participation is not restricted by age, education level, income,
problems experienced by the parent or children, or any other specific criteria. Because the
groups are community based, participants mirror the ethnic, geographical, and cultural nature of
their neighborhoods.
Treatment Components:
Parents Anonymous® Groups
•
Opportunity to discuss difficulties in child rearing (e.g., parental roles, methods for
dealing with stresses of parenting).
•
Information about child rearing (e.g., child development, alternative discipline, getting
children to cooperate, strategies to help children achieve independence and self-control).
•
A network of other parents to assist with baby-sitting, phone support, and caring
•
Information about positive parenting
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Additional Services
•
•
•
•
•
Parents Anonymous® Children’s Program runs in conjunction with Parents Anonymous®
groups
Informational seminars and workshops on a variety of subjects
Parent topic workshops
Resource and referral access
24-hour toll-free information and referral Helpline at the state and local levels
Duration of Treatment:
open-ended
Treatment Manuals or Protocol Descriptions:
Lieber, L., & Baker, J.M. (1977). Parents Anonymous® – Self-help treatment for child
abusing parents: A review and evaluation. Child Abuse & Neglect, 1, 133-148.
Rafael, T., & Pion-Berlin, L. (1999). Parents Anonymous®: Strengthening Families.
OJJDP Family Strengthening Bulletin No. NCJ171120. Washington, DC: U.S. Department of
Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention.
Rafael, T., & Pion-Berlin, L. (1996). Parents Anonymous, Inc. Program Bulletin.
Claremont, CA: Author.
Treatment Outcome Research Studies:
Pion-Berlin, L., & Polinsky, M.L. (2000). Research Profile No. 1. Claremont, CA:
Parents Anonymous, Inc.
Classification Rating:
4
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Offender Interventions
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Adolescent Sex Offender Treatment
Prepared by Mark Chaffin, Ph.D.
Brief Description:
Adolescent sex offender treatment is an intervention most often carried out in a
specialized program and usually containing a variety of cognitive behavioral techniques that are
designed to change offense supportive beliefs and attributions, improve handling of negative
emotions, teach behavioral risk management, and promote prosocial behavior.
Theory and Rationale:
A variety of treatment approaches have been used with youth that have committed sexual
offenses. These include general and non-specific mental health treatments (e.g. individual
psychotherapy, family therapy, inpatient milieu therapy), delinquency focused treatments (e.g.
standard Multi-Systemic Therapy (MST), boot camps, juvenile group homes) as well as
programs designed specifically for, and limited to, adolescent sex offenders (e.g. cognitive
behavioral sex offender group therapy, relapse prevention, arousal reprogramming techniques).
Many of these adolescent sex-offender specific programs have been based upon models used in
treating adult sex offenders. However, it should be recognized that adolescent sex offenders, as a
group, are different than their adult counterparts, and generally do not present the same kinds or
levels of sexual deviancy and psychopathic tendencies sometimes seen among adult sex
offenders (Association for the Treatment of Sexual Abusers, 1997).
At this time, there is no clear scientific evidence to favor any particular treatment
approach, or even to demonstrate that adolescent sexual offender treatment is effective at all.
Nonetheless, it does appear that short to moderate term detected sexual recidivism rates are not
high after any type of treatment. Detected sexual recidivism averages under 10% across a
variety of treatment approaches, follow-up times, and recidivism measures (Alexander, 1999).
Most outcome studies report far higher rates of non-sexual than sexual recidivism in this
population, suggesting that it is important to focus on broad behavioral goals rather than
exclusively on sexual behavior. Although the scientific outcome literature is limited, there are
commonly employed and accepted clinical practices. Many adolescent sexual offenders are seen
in specialized offender-specific programs that include peer group therapy and use some variety
of cognitive behavioral approach (Burton, et al. 1996, National Task Force, 1993). There also is
evidence to favor the MST approach (see Swenson, et al. 1998). It is generally agreed that
involving families and significant others in treatment is beneficial.
Treatment Components:
Core treatment modules
•
Psychoeducation about the consequences of abusive behavior
•
Increasing victim empathy
•
Identifying personal risk factors
•
Promoting healthy sexual attitudes and beliefs
•
Social skills training
•
Sex education
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•
•
Anger management
Relapse prevention.
Case-specific treatment components
•
Addressing personal history of sexual victimization
•
Behavioral techniques or medication designed to modify deviant sexual arousal
Parent components
•
Engendering support for treatment and behavior change
•
Encouraging supervision and monitoring
•
Teaching recognition of risk signs
•
Promoting guidance and support to their teenager.
Duration of Treatment:
30-75 outpatient sessions
Treatment Manual and Protocol Descriptions:
Henggeler, S.W., Swenson, C.C., Kaufman, K., & Schoenwald, S.K. (1997). MST
Supplementary Treatment Manual For Juvenile Sexual Offenders And Their Families, Provided
to the Institute for Families in Society, University of South Carolina by the Family Services
Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of
South Carolina.
Kahn, T.J. (1996). Pathways: A Guided Workbook for Youth Beginning Treatment.
Orwell, VT: Safer Society Press.
Kahn, T.J. (1996). Pathways Guide for Parents of Youth Beginning Treatment. Orwell,
VT: Safer Society Press.
Marsh, L.F., Connell, P., & Olson, E. (1988). Breaking the Cycle: Adolescent Sexual
Treatment Manual. Available from St. Mary’s Home for Boys, 16535 SW Tualatin Valley
Highway, Beaverton, OR 97006.
O’Brien, M.J. (1994). PHASE Treatment Manual. Available from Alpha PHASE, Inc.,
1600 University Ave., West, Suite 305. St. Paul, MN. 55104-3825.
Steen, C. (1993). The Relapse Prevention Workbook for Youth In Treatment. Orwell,
VT: Safer Society Press.
Way, I.F., & Balthazor, T.J. (1990). A Manual for Structured Group Treatment with
Adolescent Sexual Offenders. Notre Dame, IN: Jalice.
Treatment Outcome Study References:
Borduin, C.M., Henggeler, S.W., Blaske, D.M., & Stein, R.J. (1990). Multisystemic
treatment of adolescent sexual offenders. International Journal of Offender Therapy &
Comparative Criminology, 34, 105-113.
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Classification Rating:
3
-95-
Adult Child Molester Treatment
Prepared by Donya L. Adkerson, M.A., L.C.P.C.
Brief Description:
Adult child molester treatment uses cognitive behavioral and adjunctive therapies to help
child sexual offenders develop the motivation and skills to stop sexual offending by replacing
harmful thinking and behaviors with healthy thoughts and the skills to make choices that will
reduce risk. Specialized treatment typically includes individual or group therapy with additional
intervention through education of, and monitoring by, collaterals in offenders’ environment.
Theory and Rationale:
Sexual molestation of children is a treatable though not curable behavior problem, and
most offenders require external motivators to successfully complete the treatment process
(Association for the Treatment of Sexual Abusers, 2001). Sexual child abusers are a
heterogenous group who may have a variety of psychological and behavioral problems or show
no psychopathology beyond their sexual interest in a particular child (Salter, 1995). The
problem may involve sexually deviant sexual interests in pre-pubertal children or the
unwillingness to abide by social expectations and laws prohibiting sexual relationships with
under-age adolescents. Many child molesters have committed additional types of sexual
offenses, and intrafamilial offenders may well have extrafamilial victims (Abel et al., 1988;
Salter, 1995). Child molesters with male victims show higher recidivism rates than those with
only female victims (Alexander, 1999; Hanson, 1997; Maletzky, 1993). While multiple
etiological pathways to sexual offending are probable, effective intervention focuses on
modifying those factors that support the desire, capacity, and opportunity to offend. Cognitive
behavioral approaches are currently considered the most effective methods of treatment, with
pharmacological, educational, skills-building, self-help, and other methods used as adjuncts to
treatment (Association for the Treatment of Sexual Abusers, 2001). An analysis of 79
treatment studies found that treatment of child molesters by Relapse Prevention and other
cognitive behavioral approaches brought known recidivism rates to 8.1%, compared to 18.3%
for other treatment approaches and 25.8% for untreated molesters (Alexander, 1999). The
presence of sexual deviancy and psychopathy substantially increases the risk of recidivism.
There is currently no known effective treatment for psychopathy.
The desire to be sexual with a child is generally rooted in deviant sexual arousal patterns
and/or inadequate competency in meeting psychosocial and sexual needs in consensual adult
relationships. Dysfunctional core beliefs and ongoing distorted thinking are used by the offender
to justify and facilitate the sexual offense behavior. Some offenders turn to sexual fantasy and
offending in response to specific disinhibitors, such as negative affective states, while others
actively approach offending as an ego-syntonic goal (Ward, Hudson, & Keenan, 1998).
Psychophysiological assessment techniques (e.g., plethysmography, polygraph) are useful, as
most offenders enter treatment demonstrating denial and minimization of part or all of their
offense history and arousal patterns. Such client denial complicates both accurate initial
assessment and ongoing evaluation of treatment progress. Therapy that addresses the specific
elements of the offender’s beliefs and feelings that lead to sexual offending behaviors and
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includes an individualized relapse prevention component is currently considered the approach
most likely to decrease new sexual offenses.
Treatment Components:
Core Therapeutic Tasks
•
Implement environmental changes to reduce opportunity for sexual offense
•
Develop personal accountability for the complete sexual offense history
•
Modification and management of deviant arousal patterns
•
Identify and correct dysfunctional core beliefs and faulty cognitions
•
Identification of offense cycle (all factors--emotional, perceptual, cognitive, behavioral-that increase personal risk for sexual offending)
•
Develop and implement practical strategies to interrupt the offense cycle and replace past
responses with healthy behaviors
•
Understand the extent of harm to victims from sexual offending and increase motivation
to refrain from harming others
Adjunctive Therapeutic Tasks, as needed
•
Social/sexual education and skills building
•
Education and support for collaterals who support and monitor the offender
•
Intervention for concurrent problem areas (e.g., substance abuse, anger management)
•
Trauma resolution
•
Relationship therapy
•
Reunification therapy (This should be undertaken ONLY if/when the offender has made
significant gains in treatment, is showing full accountability, demonstrates ability to
manage deviant arousal; the non-offending parent is appropriately trained and motivated
to protect the children both physically and emotionally; AND reunification work is in the
best interest of the children.)
Duration of Treatment:
1-2 years of active treatment; weekly individual and/or group
sessions
Treatment Manuals or Protocol Descriptions:
Association for the Treatment of Sexual Abusers. (2001). Practice Standards and
Guidelines for Members of the Association for the Treatment of Sexual Abusers. Beaverton, OR:
Author.
Abel, G.G., Becker, J.V., Cunningham-Rathner, J., Rouleau, J.L., Kaplan, M., & Reich,
J. (undated). The treatment of child molesters. Atlanta, GA: Author.
Bays, L., & Freeman-Longo, R. (1989). Why did I do it again? Understanding my cycle
of problem behaviors. Holyoake, MA: NEARI Press.
Bays, L., Freeman-Longo, R., & Hildebran, D.D. (1990). How can I stop? Breaking my
deviant cycle. Holyoake, MA: NEARI Press.
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Barbaree, H.E., & Seto, M.C. (1997). Pedophilia: Assessment and treatment. In D.R.
Laws and W. O’Donohue (Eds.), Sexual Deviance: Theory, Assessment, and Treatment (pp.
175-193). New York: Guilford.
Freeman-Longo, R., & Bays, L. (1988). Who am I and why am I in treatment?.
Holyoake, MA: NEARI Press.
Salter, A.C. (1988). Treating Child Sex Offenders and Victims. Thousand Oaks, CA:
Sage Publications.
Treatment Outcome Study References:
Alexander, M.A. (1999). Sexual offender treatment efficacy revisited. Sexual Abuse: A
Journal of Research and Treatment, 11(2), 101-116.
Dwyer, S.M. (1997). Treatment outcome study: Seventeen years after sexual offender
treatment. Sexual Abuse: A Journal of Research and Treatment, 9(2), 149-160.
Hanson, R.K., Gordon, A., Harris, A.J.R., Marques, J.K., Murphy, W., Quinsey, V. L., &
Seto, M.C. (2002). First report of the collaborative outcome data project on the effectiveness of
psychological treatment for sex offenders. Sexual Abuse: A Journal of Research and Treatment,
14(2), 169-194.
Hanson, R.K., Steffy, R.A., & Gauthier, R. (1992). Long-term follow-up of child
molesters: Risk prediction and treatment outcome. (User Report No. 1992-02.) Ottawa:
Corrections Branch, Ministry of the Solicitor General of Canada.
Classification Rating:
2
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Summary of Treatment Protocols
Table 1 presents a summary of the 24 treatment protocols reviewed and their
classifications on the factors assessed. Concerning their theoretical basis, eight were judged to
have employed a somewhat novel, but reasonable approach to the use of psychological
principles. The theoretical foundation of one protocol was considered questionable and
unacceptable. All other protocols were rated as having a sound theoretical basis in generally
accepted psychological principles. Regarding the quantity and quality of the clinical/anecdotal
literature describing the use of the protocol, five were assessed as having relatively little
literature available about their use with abused children and their families, and eight were rated
as having “Some” clinical literature that could be examined. The other protocols have
substantial clinical literatures describing their use with abused children and their families. As
for acceptance and use within the child abuse treatment community, nine protocols were judged
as having “Some use,” while five had only limited use. The other 10 protocols were rated as
having wide acceptance by practitioners working with child abuse victims and their families.
The potential risk for harm vs. the potential benefits of the treatment were an important
factor considered by the National Advisory Committee. Unlike psychopharmacological
treatments, the risks of psychotherapy are rarely discussed. However, all therapies carry a
potential for harm, and this possibility needs to be recognized and balanced against the potential
benefit of the treatment. Therefore, a careful evaluation of the potential for harm vs. the likely
benefit of a treatment is critical when determining its utility and acceptability for use in the field.
Of the 24 treatments, most were judged to have little risk in their implementation. Six were
assessed as carrying some risk, but the level of risk was acceptable given the potential benefits of
the treatment. Several of the protocols viewed as having some risk involve the treatment of
abusing parents, or are protocols for deciding if and implementing how abusing parents should
have contact with their child victims. By their nature, these interventions involve a degree of
risk since they involve treating parents who have been physically or sexually violent. However,
they are rated as acceptable because the core purpose of the treatment is to reduce the violence
potential of parents, thereby reducing risk to children. Presumably, children will benefit by
maintaining the parent-child relationship in some form. In these cases, the benefits of the
interventions` were judged to outweigh their risks.
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Table 1. Summary of Treatment Protocol Classifications
Treatment Protocol
CHILD-FOCUSED
INTERVENTIONS
CBT/Psychodynamic
Children with Sexual Behavior Problems
Cognitive Processing Therapy (CPT)
Eye Movement Desensitization and
Reprocessing (EMDR)
Child/Parent Physical Abuse CBT
Resilient Peer Training Intervention
Therapeutic Child Development Program
Trauma-Focused CBT
Trauma-Focused Integrative-Eclectic
Therapy
Trauma-Focused Play Therapy
FAMILY, PARENT-CHILD,
PARENT-FOCUSED
INTERVENTIONS
Attachment-Trauma Therapy
Behavioral Parent Training
Corrective Attachment Therapy
Family Focused, Child Centered
Treatment
Family Resolution Therapy
Treatment of Dissociative
Symptomatology
Intensive Family Preservation
Theoretical
Basis
ClinicalAnecdotal
Literature
Acceptance/
Use in Clinical
Practice
Potential for
Harm
Risk/Benefit Ratio
CBT-Sound
Dynamic-Novel
Sound
Novel/
Reasonable
Sound
Sound
Sound
Sound
Sound
Substantial
Little
Substantial
Substantial
Accepted
Limited use
Accepted
Some Use
Little Risk
Some Risk
Little Risk
Little Risk
3
Substantial
Little
Substantial
Substantial
Substantial
Accepted
Limited use
Accepted
Accepted
Accepted
Little Risk
Little Risk
Little Risk
Little Risk
Little Risk
3
3
3
1
3
Sound
Substantial
Accepted
Little Risk
4
Novel/
Reasonable
Sound
Questionable
Novel/
Reasonable
Novel/
Reasonable
Novel/
Reasonable
Sound
Some
Accepted
Little Risk
4
Some
Little
Some
Some use
Limited use
Some use
Little Risk
Substantial Risk
Some Risk
3
6
3
Some
Some use
Some Risk
4
Some
Some use
Little Risk
4
Substantial
Accepted
Little Risk
4
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Empirical
Support
3
3
Multisystemic Therapy (MST)
Sound
Little with
child abuse
Parent-Child Education/Physical Abuse
Parent-Child Interaction Therapy
Physical Abuse Family Therapy
Parents United
Sound
Sound
Sound
Novel/
Reasonable
Novel/
Reasonable
Sound
Sound
Parents Anonymous
OFFENDER INTERVENTIONS
Adolescent Sex Offender Therapy
Adult Child Molester Therapy
Little Risk
3
Substantial
Some
Little
Some
Limited use
with child
abuse
Some use
Some use
Limited use
Some use
Little Risk
Little Risk
Little Risk
Some Risk
3
3
3
4
Some
Some use
Some Risk
4
Substantial
Substantial
Accepted
Accepted
Some Risk
Some Risk
3
2
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The empirical support for each of the 24 protocols reviewed were categorized according
to the classification system described above. The results are described below:
Classification
Number
1.
Well-supported, efficacious treatment
1
2.
Supported and probably efficacious treatment
1
3.
Supported and acceptable treatment
14
4.
Promising and acceptable treatment
7
5.
Innovative or novel treatment
0
6.
Concerning treatment
1
24
Of the 24 treatments reviewed, 16 had at least some empirical support for their efficacy with
cases of child abuse. However, only one, Trauma Focused Cognitive-Behavioral Therapy, met
the standards of the highest category, and only one, Adult Child Molester Therapy, was rated in
the second highest category. Of the 14 having at least some empirical support (category 3),
several have very strong empirical support when used with other client populations, but have not
been tested specifically with child abuse victims or their families. However, many of these have
been used clinically with abuse victims with positive results. These include well-known
treatments such as Behavioral Parent Training, Cognitive Processing Therapy, Multisystemic
Therapy (MST) and Eye-Movement Desensitization and Reprocessing (EMDR). Therefore,
results of this review show that there are a substantial number of empirically supported
treatments available to practitioners working with child victims of abuse and their families.
Empirically supported treatments are available for use with problems experienced by child
victims, with problems in parent-child relationships, and with abusive parents. These treatments
should be considered first choice treatments when working with child victims and their families
who have problems targeted by these protocols, and they are recommended for use.
It should be noted that even for these empirically supported treatments, the level of
support enjoyed by all but a few is rather thin. Many have only one uncontrolled outcome study
backing their efficacy (e.g., Trauma-Focused Integrative-Eclectic Therapy). Some have multiple
randomized controlled trials supporting their utility with other populations and are clearly
efficacious treatments (e.g., Behavioral Parent Training). But, they have not been tested
specifically with abused children and their families. To date, none has undergone a true
effectiveness trial with child abuse victims and their families, though admittedly, such trials are
relatively rare in all aspects of mental health treatment. Therefore, much clinical outcome
research remains to be done to test further the efficacy and effectiveness of all of these
treatments with children who have been abused and their families.
Practitioners should note that several well-known and commonly used treatments have no
empirical support for their efficacy. For example, Trauma-focused Play Therapy is often used
with young victims of abuse. It was judged to have a strong theoretical base, have an excellent
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clinical literature, carry little risk, and be widely accepted within the field. Yet, it has no
empirical evidence to support its claimed therapeutic effects. Therapies such as this one are
prime candidates for future research testing their efficacy. Many of these theoretically sound
and widely used therapies may be helpful to clients as indicated by the clinical/anecdotal
literature. However, the burden is on the developers and proponents of these treatments to
provide empirical evidence of their effects before they can be recommended with more
confidence.
One protocol, Corrective Attachment Therapy, was rated as having a “Substantial” and
unacceptable level of risk and was rated 6, Concerning. This judgment was made for several
reasons. First, it was assessed as having a questionable theoretical basis. Recent literature has
suggested that this treatment is a misuse and misapplication of theories of child development and
childhood interpersonal attachment processes (Speltz, 2002). Second, the techniques and
procedures associated with this protocol were judged to be excessively coercive. Because of the
coercive nature of the treatment, the protocol was judged to carry a significant risk for causing
psychological and physical harm to children. Third, because of the nature of the procedures
used, the treatment was evaluated as having great potential for misuse and misapplication.
Fourth, this protocol has a very rare distinction among psychotherapies in that deaths of children
receiving this treatment have been reported (Crowler & Love, 2000). These deaths reinforce
concerns about the safety of children receiving this intervention. One small (N = 23) outcome
study has suggested pre- to post-treatment improvement on parent-rated aggression and
delinquency behaviors by children receiving “Holding Therapy” (Myeroff, Mertlich, & Gross,
1999). Despite this finding, any benefits of this treatment that would outweigh its considerable
risks are not clear. Therefore, given the significant risk for negative consequences to children,
even death, and the lack of convincing evidence of its therapeutic benefit, Corrective Attachment
Therapy was determined to constitute a substantial and unacceptable risk of harm to child
victims and their families. Therefore, this treatment cannot be recommended, and its use is
discouraged.
The results above reveal that practitioners working with child abuse victims and their
families have several empirically supported treatments available to them that target common
problems in the individual and parent/family domains. If an empirically supported treatment
exists for a target problem, clinically accepted but unsupported treatments should be viewed as
alternative or second-choice therapies. Decisions to use alternative therapies in the place of first
choice treatments should be made carefully, with due consideration to all of the issues involved
in such a decision. Practitioners considering using alternative rather than first choice therapies
should make such decisions cautiously, and consider seeking consultation from knowledgeable
peers. When empirically supported treatments are not available, practitioners should use
theoretically sound and widely accepted treatments that have an acceptable level of risk.
Concerning treatments, those with few proven benefits and substantial risk, should be avoided.
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GENERAL PRINCIPLES FOR TREATMENT
OF PHYSICAL AND SEXUAL ABUSE
Principles of Empirically Supported Treatments
Child victims of physical or sexual abuse very often have complicated histories of
multiple victimization and trauma, and exhibit a variety of disorders, problems, and difficulties
that may or may not be the direct result of abuse (Saunders, in press). Complex histories and
multiproblem presentations are considerable assessment and treatment challenges for
practitioners. How should children with multiple problems be treated? Should several treatment
protocols be employed, one for each problem? What about child victims of both sexual and
physical abuse who may have histories of other traumas as well? Should treatments be
combined, delivered concurrently, or staged sequentially? It may be helpful for practitioners
confronted with these difficult children to use approaches that are shared across empirically
supported treatments. The shared theoretical perspectives, treatment procedures, and clinical
skills associated with these protocols can be flexibly applied depending on the history, problem
matrix, and circumstances of these complex cases.
As presented above, many treatments have been developed for the disorders, conditions,
and problems commonly seen in child victims of physical and sexual abuse and their families.
Generally, the interventions with the most empirical support tend to be based on behavioral or
cognitive behavioral theoretical approaches, utilize behavioral and cognitive intervention
procedures and techniques, and intervene at both the individual child and parent/family levels.
Many of them share specific treatment procedures and techniques (e.g., cognitive restructuring,
exposure procedures, behavioral management skills) that are simply applied to different
problems. When examined with complex case presentations in mind, empirically supported
protocols have certain common principles and treatment components that can be applied to many
different problems children and families may have. Therefore, it is important to identify the
common principles and components shared by empirically supported treatment protocols.
In general, treatments with empirical support are goal directed. They are designed to
address specific, measurable problems identified through systematic assessment of children and
their families. Problems are defined and identified such that they can be measured using sound
and accepted assessment tools. Once the problems are defined and measured, a treatment plan
can be developed for reducing them, and the effect of the treatment can be assessed over time.
Empirically supported treatments tend to be structured in their approach. They have
specific procedures and techniques that are used in order to reduce the problems assessed. Little
time is devoted to non-goal directed activity other than for the purpose of rapport building and
engaging the client in the therapeutic procedures. These treatments often have a sequential
staging of treatment components that are designed to build upon one another until the therapeutic
goals are reached. Because of their structure, therapists using these treatments are more likely to
stay focused on the larger goals of treatment and not get sidetracked by the inevitable daily
problems and “crises” that often arise with this client population.
Empirically supported treatments usually emphasize skill building to manage emotional
distress and behavioral disturbance. Children are taught specific skills for self-regulation of their
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thinking, affect, and behavior. Parents are taught skills for managing children. Treatment
components often are variations of basic cognitive-behavioral techniques, and usually include
didactic procedures such as psychoeducation, expressive procedures such as exposure therapy,
cognitive procedures such as cognitive restructuring, and child behavior management
techniques. These procedures are designed to teach and build skills to manage the targeted
problems.
Empirically supported treatments typically use techniques involving repetitive practice of
skills with therapist feedback. Practice occurs both within treatment sessions and between
sessions in the home, school, or community. The use of role-plays and homework is common in
these therapies. These learning strategies maximize the likelihood that newly acquired skills will
generalize to every day life.
For children, there are several key skills that are common among empirically supported
treatments within child mental health, and are also components many of the supported treatments
described above. These elements include: (1) skills for emotion identification, processing, and
regulation, (2) anxiety management skills, (3) skills for the identification and alteration of
maladaptive cognitions, and (4) problem solving skills. All of these skills are applicable to
reducing the most common problems that may be the direct impact of abuse. However, they also
are useful in addressing the additional problems and difficulties that many abused children have.
These general skills cut across the treatment of a variety of emotional and behavioral disorders
and can be considered basic and fundamental treatment components. Therefore, clinicians
working with abused children should be knowledgeable and skilled in the use of these
procedures.
When dealing with children, especially if they have concerning abuse related behavioral
reactions or externalizing behavior problems, it is necessary to include treatment components
that address the child’s environment. For most children, this means working closely with their
parents or caregivers and their larger family system. The general principle of treatment for
parent-child relationships is to promote positive interactions between parents and children while
reducing negative interactions. This goal is accomplished through several approaches. Parents
are taught to use effective behavior management skills based upon reinforcement of positive
behavior, rather than relying primarily on punishment of negative behavior. Parents are taught
the importance of consistency and follow through as essential ingredients for changing child
behavior. They are taught (1) skills to reward and reinforce all manifestations of positive
behavior, (2) how to strategically ignore minor or irritating behavioral problems, (3) how to give
effective instructions, and (4) how to implement nonviolent consequences such as time-out or
the removal of privileges. Parents are also taught how to recognize and avoid the development
of negative interactions with their children, and techniques for constructing positive experiences
and increasing their frequency.
As can be seen for the treatment descriptions presented above, nearly all of the
empirically supported treatments contain some form of these therapeutic elements. They are
goal-directed, structured in their approach, and teach appropriate skills to children and parents.
Therefore, even when confronted with complex situations of abuse, practitioners can begin with
this core set of approaches and adapt and add to them as necessary.
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General Principles of Treatment
While each case of intrafamilial child abuse presents unique challenges, current scientific
knowledge about the effects of child abuse and the efficacy of intervention suggests several
general principles of treatment that can be applied to most cases. They are based upon the
relevant scientific literature, and findings from the field’s years of clinical experience treating
abused children. Like any guidelines, these principles are not meant to be followed lockstep in
every case. Rather, they offer direction and basic precepts that can be used to guide treatment
planning.
1.
Children’s abuse experiences should be acknowledged and characterized as wrong,
unlawful, and harmful in all abuse-specific interventions with children, families, and
parents. Child abuse is never acceptable or warranted. Offending parents often have a
rationale for their abusive behavior that is based upon distorted ideas of child welfare.
Interventions should guard against being co-opted by these rationales.
2.
Children’s physical and emotional safety should be assessed and given significant weight
in treatment planning and the interventions undertaken. It is unlikely that any child can
be placed in an absolutely safe environment. However, a reasonable and acceptable level
of safety should be established in the child’s environment prior to treatment for problems
related to abuse. It is unlikely that children continuing to live in situations that they
consider to be dangerous or threatening can be treated successfully. Safety should be
maintained throughout course of treatment, and should be a criteria for discharge from
treatment.
3.
Systematic clinical assessments of children and parents for both abuse-related and
general mental health and behavioral problems should be conducted prior to initiating
therapy. Results of systematic clinical assessments should form the basis for all
treatment plans.
4.
Systematic clinical assessment should include a comprehensive examination of the
child’s lifetime victimization and trauma history. Such an examination is not a forensic
evaluation conducted to gather evidence for legal purposes. Rather, it is a clinical
examination designed to assess the child’s relevant history, and identify problems that
will be the targets of treatment.
5.
Systematic clinical reassessment of children and parents should be conducted at periodic
intervals to determine treatment progress and provide information on which to base
revisions to treatment plans and treatment focus.
6.
Interventions should be selected and matched to the problems, disorders, and conditions
identified in the systematic assessments of abused children and their parents.
7.
Treatment protocols with the highest levels of empirical and clinical support for their
effectiveness with the specific problems identified in the assessment process should be
used as the first choice interventions for abused children and their parents.
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8.
Therapy is not a risk-free endeavor. Clinicians should be aware of potential harmful
effects of therapy and assess the potential risks of any treatment. The potential benefits
of a treatment should be balanced against its risks in the treatment selection process.
Treatments with higher than average levels of risk should not be used unless there is
convincing evidence that children will benefit greatly.
9.
Interventions with abused children should be abuse-informed. That is, interventions
should explicitly and directly address the abuse incidents experienced by the child, and
the consequent emotions, cognitions, and behaviors exhibited by the child as a result of
the abuse. The child’s maladaptive behaviors, thoughts, and feelings related to the abuse
they experienced should be the primary targets of intervention.
10.
Children should not be in treatment specifically for abuse-related problems unless the
treating clinician agrees that the child has a history of abuse.
11.
Treatment of the abuse-related problems of the child should be the central, organizing
focus of treatment, regardless of treatment modality (e.g., individual, group, parent-child,
or family therapy) or the participants in treatment (e.g., abused child, nonabused siblings,
parents, or extended family).
12.
In most cases, the term of treatment for the abused child will be short to moderate (i.e.,
12-24 sessions). However, this presumption depends on the presenting problems
assessed. Individual client differences will affect treatment duration, and a minority of
abused children will require more extended treatment.
13.
Treatment should be conducted in the least restrictive environment with the least amount
of burden on the family.
14.
The ultimate, long-term functioning and welfare of the abused child should be the
guiding principle of all treatment, regardless of modality or participants.
15.
Treatment should have as a goal the prevention of future problems often associated with
a history of abuse (e.g., substance abuse, delinquency, revictimization), as well as relief
of the current problems experienced by the child.
16.
Parental acknowledgment of the abuse, belief of the child, and support of the child should
be encouraged as part of treatment.
17.
Whenever possible, supportive, non-offending parents should be included in the
treatment of abused children.
18.
When clinically indicated, parents should receive appropriate treatment to enhance their
ability to support, care for, and effectively parent the abused child and to provide a safe
environment for the child.
19.
When clinically indicated, offending parents should receive appropriate treatment for
their abusive behavior.
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20.
When possible, treatment interventions should be used to improve the quality of parentchild relationships in abusive families.
21.
When clients have achieved the therapeutic goals, treatment should end.
22.
If it is clear that clients are not benefitting from treatment or that treatment is being
harmful, treatment should be changed or discontinued.
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CONCLUSION
Physical and sexual abuse of children is a difficult social problem affecting the growth
and development of a substantial proportion of American youth. Abused children are at
significantly increased risk for suffering a variety of medical, emotional, behavioral, relational
and social problems that can affect them lifelong. Mental health intervention with child victims
and their families can help ameliorate current problems and reduce the risk of the development
of future ones. However, this beneficial effect can occur only if effective interventions are
developed, tested, and most important, actually used with child victims of abuse and their
families. Therefore, practitioners in the field need ready access to information describing
interventions that are likely to help their clients, and they need training in the proper use of these
treatments. The goal of these Guidelines was to provide practitioners with some tools for
judging the utility of treatment protocols, and to provide them with information and direction
concerning treatments commonly used with physically and sexually abused children.
Practitioners can then use this information in their treatment planning and abused children and
their families will benefit. Ultimately, society at large that will benefit from better services
being provided to child victims and their families.
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